Summary

Death is much more common in old age than at other times of life: Approximately three-fourths of all death in the United States occur in people aged 65 years and over. Reflective of the age distribution of different ethnic groups in the United States is the fact that the death rate is slightly lower for blacks than for whites, and even lower for American Indians, Hispanics, and Asians. Differences in the age distributions of populations are also a factor in the higher death rates in Europe and North America than in Asia and South America. Because of poor living conditions, the death rate is higher in Africa than in any other part of the world. The death rate in the United States is higher during the winter months than at other times of year, being highest in the District of Columbia, and lowest in Alaska.

The three most common causes of death in the United States are heart disease, cancer, and stroke. These and other chronic disorders have replaced the acute illnesses of yesteryear as the major causes of death among Americans. Deaths due to homicide are greater in frequency during the late teens and early twenties, whereas deaths due to accidents and suicide are more common in old age. The frequency of accidental deaths and homicide are higher for men than for women, and higher for blacks than for whites. Suicide is more common among older white men than any other age or ethnic group.

Death and its symbolism have been expressed in art and literature for hundreds of years. Philosophers have been less concerned with the subject of death, preferring to leave it to theologians and the clergy. An exception are the existentialists, who emphasized that the realization of death spurs a search for meaning in life.

Separation anxiety in children is the forerunner of the fear of death in adulthood. Fear of death is less common in young and older adults than in middle-aged adults. Fears of death vary not only with age but also with personality, health, socioeconomic status, and culture. Attitudes toward death depend on individual characteristics, culture, and race/ethnicity. Religious beliefs affect death attitudes and anxiety: People who are ambivalent or indecisive about religion tend to have greater fears of death than either confirmed believers or nonbelievers.

The main criterion of death in most states is the cessation of all electrical activity of the brain, though cessation of respiration, heart rate, and reflexes are also important signs. Death of the body does not occur all at once: Different tissues and organs die at different rates. It is common practice to remove a healthy kidney, heart, or other viable organ for transplant purposes after the donor is considered medically and legally dead. In addition, the speed or pace at which dying occurs (the "dying trajectory") varies with the patient, the disorder, and the treatments administered.

Some people manifest a "terminal drop" in cognitive and sensorimotor abilities and a change in personality during the last few months of life. Although no one can consciously control the exact moment of his or her death, it is apparently possible to hasten or delay death by means of one's thoughts, feelings, and motivations.

Kubler-Ross's five-stage model of the dying process—denial, anger, bargaining, depression, acceptance—is descriptive of the psychological changes that take place in some dying patients, but the model should not be interpreted as a invariant sequence of stages through which all dying patients pass. An alternative model proposed by Pattison consists of three stages in the living—dying interval: acute, chronic living—dying, and terminal phases.

Most people die in institutions, sometimes only after extraordinary measures have been applied to keep them alive. Hospice care is a less expensive, and often more humane, alternative to hospital or nursing home care of terminally ill persons. In addition to focusing on the control of pain and discomfort, hospice care consists of discussions of death and dying between patients and staff members, and an emphasis on dying with dignity and a sense of self-worth rather than feelings of isolation and aloneness.

Open communication is preferable to the conspiracy of silence that has often pervaded social interactions with dying patients. Information about death and dying can be dealt with more effectively by terminally ill patients when it is discussed with a compassionate, companionate person. In addition to the psychological assistance provided by family members, nurses, doctors, and the clergy, the services of professional counselors may also be made available to dying persons.

Modern funerary rituals include the wake, the funeral service, and the postfuneral period. The body of the deceased is usually placed in a casket, which may or may not be open during the wake and the funeral service. The location and nature of the service and the manner in which the body is disposed of vary with the culture, religion, and other preferences of the deceased and his or her family. Although funerals have traditionally been held in churches and the body buried afterward, secular services and cremation have become increasingly popular in recent years.

Three phases of grieving over the death of a loved one have been identified: a short initial phase characterized by shock, a longer intermediate phase involving a complex of physiological and psychological reactions to the stress of bereavement, and a recovering phase beginning about 1 year after the death.

Widowhood in the United States is primarily a status of older women. The percentage of widowed persons varies not only with age and sex, but also with race/ethnicity, metropolitan versus nonmetropolitan area of residence, and geographical region. Greater percentages of widows are white, and they are more likely to live in metropolitan areas and in the Northeast. Differences in the age distributions of different racial/ethnic groups and area of residence are related to differences in the number of widows in the groups.

Loneliness can be a serious problem for both widows and widowers, but widows usually have a network of other widows to help combat their feelings of loneliness. Widowers usually make friends less readily than widows, but the availability of unmarried women enables widowers to remarry fairly easily if they so desire.

Another problem experienced by many widows is financial hardship. Lack of training in money management adds to the financial woes of widows attempting to live on reduced income. Responsibility for keeping the car, the house, and other possessions in good order is another chore that must be undertaken by most widows. These new tasks may be difficult to bear for widows who depended totally on their husbands for maintaining their home and other possessions. However, the great majority of widows are able to "get their act together" and learn to do what they must. Developing new capabilities provide widows with a sense of pride and competence and may lead to a personal reawakening. Skills and interests that have long laid dormant may be resurrected in widows' determination to take hold of their lives and get on with the business of living.

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