Week 9 Flashcards
Changes in how we view death and bereavement
Huge impact of social media: informed about deaths 24/7 news, able to immediately respond, memorials are different
Increasing wish for openness and candour
-death cafes and discussion groups
-many recent books by health practitioners
Sociological approaches to death
‘Medicalisation’ and institutionalisation
Death and funeral as a social event
Exploring the concept of the ‘good death’ in society
Observational and qualitative research in hospitals, hospices, ICU units
Sociological approaches to bereavement
Social expectations related to bereavement (who counts as bereaved and how are they meant to behave)
How does society interact with the bereaved
What are the influences of wider patterns (inequalities, gender roles)
Qualitative research on experience of bereavement
Strong interaction with practitioners
Medicalised death
Death moves from home to hospital
Decreasing importance of religious rituals
Increasing taboo
‘Power grab’- doctors make decisions
Society values youth and health; carries on by marginalising the dying and bereaved
Hospice movement/palliative care concept as a response
‘Biological’ vs ‘social’ death Sudnow 1967
Biological death- the end of the biological organism
Social death- the end of the persons social identity
Social death Lawton 2000
Ceasing full membership in active society- retirement
Loss of autonomy- moving into institutional care
Chosen by the dying person
When the body cant be controlled- the dying person is avoided or avoids others
3 types of death Walter 1996
Traditional- at home, priest, prayer, ritual, communal mourning, religious
Modern- hospital, doctor, medical intervention, crematorium, private grief, medical
Postmodern- hospice, range of practitioners, palliative care, range of option, celebration of life, personal
Glaser & strauss: awareness of dying/ time for dying
Invention of grounded theory
Interaction between the dying, clinical staff and relatives with focus on expectation and awareness of death
Timeframes and trajectories related to dying
Awareness of dying
Different dynamics around awareness between hospital staff, patients and their relatives
Closed awareness- only staff aware
Suspicion- patient suspects but not told
Mutual deception- both know but don’t talk about it
Open awareness- both know patient is dying and discuss openly
Relatives may or may not know and also ‘shield’ their family
Not knowing means patients and relatives cant make decisions; uncertainty and guilt
Awareness can fluctuate between belief and disbelief
Time for dying
Development of ‘trajectories of dying’
People die at different paces often not as expected by relatives and clinical teams
Gradual slant- long slow decline
Downward slant- rapid decline
Peaks and valleys- remission and relapse
Descending plateaus- periods of decline and stabilisation
Unexpected developments can lead to conflict or upset
Kubler-Ross 1970: stages of grief
People who know they’re dying typically pass through 5 stages:
-denial
-anger
-bargaining
-depression
-acceptance
But not necessarily linear
Similar dynamics with carers and bereaved
Advantages: helps those in a supportive role to understand how the person is feeling, why they might respond differently eg wanting support/pushing people away
Disadvantages: when used prescriptively, rushing towards acceptance/ moving on
Concepts of the ‘good death’ Hart 1998
Concept emerges in late 60/70s
Powerful with practitioners/ in popular culture
Critique of bureaucratic, institutionalised care
In practice good death is the aim but who is to blame for a bad death
Patients and carers may struggle in absence of wider support/ resources
Expectations of a good death
Do family members/nurses etc expect the patient to conform to the good death to make the experience easier for them
Avoidance of anger/depression
Others might want the dying patient to show a brave face
The hospice movement 1960s
Specialised places for palliative care including but not exclusively care in the last days of life
Care focused on comfort, personhood, family, dignity
In some ways like a hospital, in some ways like home
Can be perceived as white, middle class, Christian institution
Reliant on charitable funding- based in more affluent areas
Where do people want to die
The ‘preferred place of death’ is usually at home or hospice
Depends on who you ask, when you ask
Also understood people change their mind during course of a terminal illness
Concept of palliative care
Dying acknowledged as part of life
Dying people can/should be enabled to live as well as possible
Autonomy of the dying person
Support for family/bereaved
Main focus is improving the quality of life
Enabling good deaths; right place, comfort, with fight/acceptance
Aspects of experiencing loss
Bereavement: situation of those who have experienced significant loss
Grief- range of emotions felt by the bereaved
Mourning- visible signs of grief or the period of time in which this happens
All have social conventions attached
Social consequences of bereavement Parkes 1996
Bereaved at greater risk of:
-depression
-social isolation
-alcohol misuse
-use of prescribed and OTC drugs
-self harm
Impact of social inequality Bindley 2019
Awareness of palliative care services
Financial impact of the death adds to grief and distress
Lack of support in interaction with statutory services and bureaucracy
Lack of support from employers/ ability to take leave especially in precarious jobs
Lack of cultural competence by care providers
Social expectations bereaved
Ideal is for the bereaved person to re-engage with society/ become a well-adjusted person
Different ideas about how long this process will take
How society views the relationship between the bereaved and the deceased
Not necessarily a partner/spouse/parent
Right to grieve and have grief validated and accepted
Worden’s 4 tasks for the bereaved 1983
Steps towards a new and fulfilling life
Implies that this needs to be actively done rather than being an effect of time passing
-accept the loss
-work through grief
-adjust to a new environment
-to find an enduring connection with the deceased
Moving on vs staying connected
What is healthy grief and mourning opinions differ depending on time and place
Some warn of the danger of being stuck in the past or socially isolated
Filling the emptiness, keeping busy,, helpful or not over long term?
Current ideal is to stay emotionally connected while still being able to carry on living
There may be unhelpful pressure to move on from other people
Role of the doctor with those who are dying or grieving
Treating, curing, averting death
Breaking bad news
Symptom control
Discussing patient wishes
Completing death certificate
Differences between groups of people
Human beings are complex creatures
One aspect of this is our tendency to organise into groups and consider ourselves as part of those groups
We also consider how other group are different
This phenomen has been studied as social identity theory
Social groups
Social groups will often develop ways of being that allow identification of other group members
The phenomenon is known as habitus:
The way they present themselves to others
This might include the way they dress
They way they talk- accent, language, tone of voice
The way they walk or stand
This habitus of a group reflects the aesthetic preferences of those who have power within the group
Doctors social group
A lot of your credibility as a professional relies on your ability to seem like a doctor
Look right, act right, talk right
Social identity theory posits that the more doctor-y you seem the easier you will find it to find acceptance, power and influence within the group
Traditional doctor habitus in UK: firmly upper middle class, white, male
Identity dissonance Yang Costello 2015
This poses no problem at all for those who are already from the correct background
But other people have to learn to act the right way
Professional identity doesn’t just happen
It takes time to see oneself as a member of the new group
It’s not just about looking the part, sounding the part
It’s not even just about being accepted as a member of the group
It’s also about successfully internalising the values of the new group
Values and behaviour
Values and beliefs are about what’s important and how things should be
We all hold multiple values across contexts
Values are of interest to psychologists and sociologists because they are one of the most important determinants of behaviour
Explicit professionals values
The GMC and other bodies provide us with professional values
Honesty, probity, reliability, responsibility
Medical schools council list the values expected of applicants:
Respect for others, responsibility, integrity, empathy
Values of humanistic care: whole person care, respect for peoples intrinsic value, considering others perspectives, suspending judgements, recognising universality, relational focus
Possible trajectories
Adapted from coulehan and Wilson 2001
Students: explicit professionalism, cognate professionalism, tacit professionalism
Cognate professionalism
Coulehan and Wilson 2001
When asked many doctors say they espouse professional values
They are able to behave accordingly to prescribed professional values when they are thinking about it
However when watched the behaviours they display when they are not thinking about it are anchored in a quite different set of values
Tacit professionalism ‘the hidden curriculum’
Coulehan and Wilson 2001
A position of self interest with values based around objectivity, detachment and wariness
Informal and procedural knowledge- how things are done Hafferty 2015
Consequences of hidden curriculum
Loss of idealism and acceptance of hierarchy (Sinclair 2020)
Neutralisation of emotions (hellman 1991)
Detachment and entitlement (coulehan and Wilson 2001)
Hidden curriculum borgstrom et al 2010
Conflict between old and new professional values
The hidden curriculum as lag in medical culture as medicine shifts from a paternalistic to a patient centred model
Professional identity coulehan and Williams 2001
Three possible outcome:
Narrow to being a technician adopt tacit
Non reflective professionalism
Internalise professional virtue adopt explicit
Values determine behaviour subconsciously
Cognate professionalism does not lead to the right behaviours most of the time
The system
The other thing we need to consider here is the system doctors work in
High pressure
Understaffed and under resourced
Punitive when things go wrong
Competitive
Traumatic
Little or nothing in the way of psychological support
Loss of sense of community
Professional values are expensive
Difficult to meet the needs of others when own needs aren’t met
The vast majority of unprofessional behaviour is seen in highly pressured stressful situations
Overworked and overstretched People will experience burnout
System must be revised and resources allocated improved to prevent circumstance undermining professional behaviour
Role models
Many medical students have role models for their professional behaviour
We will often internalise the values of role models easily and without deeper consideration
Think about professional behaviour you’re seeing rather than simply accepting it
In-groups and out-groups
Social groups to which a person does/does not psychologically identify as being a member
Individuals belong to many different in groups and out groups
In groups give use a sense of social identity
Important source of pride and self esteem
Allow us to find out things about ourself
Helps us to define socially acceptable behaviour
What is stereotype
“ a widely shared assumption about the personality, attitude or behaviour of a person based soley on their group membership” Hogg and Vaughan 1995
Positive or negative
Based on accident fallacy (sweeping generalisation)
How are stereotypes formed: personal experience, culturally received information, role models/ family members , the media, encoded by language, generalisation, identifying exceptions
Explicit or implicit- implicit association test
Why do we stereotype
Social function: allows us to learn from the experience of others
Cognitive function: simplify and systemise information about the world, reduces processing time, enables us to respond quicker to situations
