Module 4 End of Life Decisions & The Funeral Process

END OF LIFE DECISIONS: ADVANCED DIRECTIVES

Part 1

Advance Directives

• Documents that specify the type of health care an individual wishes to receive should that individual not be in a position to express his or her wishes in a critical situation • Living Will (introduced in 1968) • Self-Determination Act (state legislation started in

1976 in California) • Established health care proxies and durable power of

attorney clauses

Patient Informed Consent

• The legal right to refuse treatment • Patients must be given adequate information

regarding: • Nature of the proposed treatment • Probabilities of success • Possible side-effects • Other treatment options (and no-treatment option)

Living Will • Advantages

• First advance directive • Empowered individuals to make their choices known • Brought private, public, and professional awareness

to end-of-life issues and decisions • Disadvantages

• Can be ambiguous in interpretation • Doesn’t include provisions for assisted death • May not be available to medical care providers when

needed

The Patient Self Determination Act • Started in California in 1976; now laws passed in every

state • Recognizes a mentally competent adult’s right to refuse

life support procedures • Patients were given the right to designate a person who

would see that the advance directive is respected if they were unable to act in their own behalf • Designated person = a health proxy • Responsibility give the health proxy is durable power of attorney

for health care

Facts about Advance Directives (Sabatino, 2005)

• They are legal in every state

• One that is legal in one state is generally legal in all states

• Can change the wording of preprinted forms

• A lawyer is not required to make it a legal document

• It doesn’t restrict treatment efforts within accepted medical standards; allows for pain control and comfort care

• Health care providers are legally obligated to follow it

A Right Not to Die? The Cryonics Alternative • Available since 1967 • Choosing to have your certified dead body

placed in a hypothermic (frozen) condition for the possibility of resuscitation at a later time

• No attempts have been made (yet) to resuscitate from a cryonic state

• First person to chose a cryonic alternative was a psychologist, Dr. James H. Bedford

The Cryonics Alternative: Three Purposes or Visions • Restoring a “dead” person to continue his/her

life where it had left off (perhaps with a cure to their terminal illness)

• Equipping the reanimated with a body that will be resistant to aging and other forces of mortality

• Reanimating the brain so that it may grow a new body in the future

Cryonics: Radical New Developments • Neural Preservation (head only) has replaced

whole-body • Focus is on brain preservation • A body can be regenerated from neural DNA

• The cooled tissues are vitrified (transformed to a stone-like substance) • Replaces water inside cells with antifreeze

compounds • Temperature is dropped to -130 degrees Celsius • Flesh turns into a form of glass

Organ Donation

• Kidneys and livers are the most needed • Restraining influences on the number of

successful transplantations: • Willingness of people to donate • Condition of the donated organs • Biological match between donor and recipient • Overall condition of the recipient • Expense and timely delivery

Copyright © Allyn & Bacon 2007

Organ Donations • Approximately 7,000 people donate organs while

they are still alive (such as donating a kidney) • Victims of fatal motor vehicle accidents are one of

the most available sources • About 75,000 people are on the waiting list is the

U.S. at any given time • Demand and short supply creates:

• Discrimination • Conflict • Illegal sales of organs to affluent clients

Module 4: Part 3

Funeral-Related Decisions • Funeral homes are required to provide a price

list • Do thorough comparison shopping • Be aware of additional charges for additional

services and products • Do not hesitate to inquire about simple and

immediate burials or about cremation • The most expensive item in a traditional funeral

is the casket • Use good judgment to resist services or

products that your family really doesn’t want

From Dead Body to Living Memory: A Process Approach • Premortem Preparations may include:

• Financial and employment matters • Funeral arrangements • Attention to personal relationships

• Immediate Postdeath Activities • Certification by a physician • Contact relatives and friends • Cleanse and wrap the body

From Dead Body to Living Memory: A Process Approach • Preparation for Burial or Cremation

• Allows for friends and relatives to gather • Funeral arrangements must be make • Insurance companies consulted • Other financial arrangements made • Allows time for embalming, mummification, or

whatever means the culture uses to preserve bodies • Death must by certified by a physician

• Death certificate records are often missing potentially important information

From Dead Body to Living Memory: A Process Approach

• The medical examiner (coroner) reviews the case • Autopsy needed? • Death investigator (medical specialist) needed?

• May involve an Autopsy • Performed by the coroner or medical examiner • Requires permission from the next of kin • Sometimes needed to understand a condition that

poses a threat to the community • Sometimes there is suspicion of negligence, error, or

homicide

From Dead Body to Living Memory: A Process Approach • Settling into the Earth

• Most Americans are placed horizontally on their back • Most common is fetal position (to sleep or be reborn)

• Cremation • Preferred by most ancient cultures (except Egyptians) • Opposed by Christianity until the Reformation by Luther • Some concern today over toxic gas emissions • Utilized in the U.S. about 25% of the time, 63% of the time

in Europe, and 95% of the time in Japan • Rare in Islamic counties, Israel, and sub-Saharan Africa

From Dead Body to Living Memory: A Process Approach • The Funeral Service

• Held for whole body burials and cremations • Many decisions to be made in designing the

ceremony • Serves two purposes

• Final placement of the remains • Public recognition of the death

• Memorializing the Deceased • Obituaries • Grave markers • Personal rituals, prayers, gifts, sacrifices

What Does the Funeral Process Accomplish? • Create or solidify the place of a hero

• Ch’in, 1st Emperor of China, built a palace as a burial tomb to support his claims to greatness and immortality, secure succession, confound enemies, and impress deities

• Queen Victoria created an elaborate funeral for Prince Albert that symbolically incorporated him into the British Empire and demonstrated the Victorian sentiment

• Lenin’s corpse was placed in a grand mausoleum as a “patron saint,” even though he had no use for religion

What Does the Funeral Process Accomplish? • Balance the claims of the living and dead

• In Potamia, northern Greece, villagers (mostly the women) tend temporary graves for 5 years, then bones are transferred to the bone house

• The survivors are obligated to tend the graves • Kotas, southern India, cremate the dead and carry out

two funerals, Green and Dry, for purification • Orthodox Jews have a special time called Aninut,

devoted to honoring the dead and reflecting on the loss

Cemeteries in the United States • Colonial times

• Dead buried in churchyards or city cemeteries • Quickly became crowded and chaotic

• 1796, New Haven Burying Ground • Better planned; the first to offer “family plots”

• Mount Auburn Cemetery, Cambridge, MA • Introduced landscaped, park-like atmosphere

• National Cemetery System for veterans • President Lincoln’s Gettysburg Address (November

11, 1863) was given to dedicate the first national cemetery

Cemeteries in the United States • Neighborhood Cemeteries

• Still active though some are in the midst of urban decay

• Examples of Ethnic Cemeteries • Afro-American Section, The Common Burying

Ground, Newport, Rhode Island • Navajo and Mormon companions at the Ramah

Cemetery, Ramah, New Mexico • Mexican-Americans in San Antonio’s San Fernando

Cemetery

When Are the Dead Important to the Living? • The dead are more secure in past-oriented societies

• Future-oriented societies may look to technology rather than wisdom and achievements of the past

• Geographical detachment from the dead will cause distress to the living, especially in past-oriented societies • Also disrupts their sense of tradition and culture

• The dead will be remembered and “used” more often in societies in which children are highly valued as continuing the family soul over the gap created by death

When Are the Dead Important to the Living? • Longer life expectancy and low vested power of the

elderly make the dead less important • More people are older (not unusual) and have fewer

resources • A society lacking unifying and transcending themes will

assimilate the funeral and memorialization process into its utilitarian motives • Dead may live on through organ donation rather than

memories, tradition, or social identity because of the emphasis on function

• Societies that live close to nature need the assistance of the dead to promote fertility and regeneration

Recent American Memorials • Vietnam Veterans Memorial

• Black stone suggests mourning and reflection • Names are given in order of their deaths while rank,

unit, and home state were ignored • Many people bring items to leave at the memorial

• World War II Memorial • Built after the Vietnam Veterans Memorial • Took many years of advocacy and private fundraising • Dedicated in 2004

Recent American Memorials • World Trade Center Memorial

• Memorials have been established at the Pentagon and in rural Pennsylvania

• Much discussion and controversy of the purpose and design of the NYC memorial

• Oklahoma City National Memorial • Includes a chair in remembrance of all who died • Includes a museum that charts the chain of events

and honors each individual who died with a personal object

• Includes an education and outreach service

The Treatment of Human Remains: The Vermillion Accord • Universal respect shall be given to the mortal remains of

the dead

• Disposition of human remains will be made in accordance with the wishes of the dead themselves whenever this is known or can be reasonably inferred

• The wishes of the local community will be respected “whenever possible, reasonable, and lawful”

The Treatment of Human Remains: The Vermillion Accord • The scientific value of studying human remains will be

respected whenever such value can be demonstrated to exist

• Negotiations with an attitude of mutual respect shall be conducted to accommodate both the legitimate concerns of communities for the proper disposition of their ancestors and the legitimate concerns of science and education

Challenges and Developments: The Funeral Director’s Perspective • Directors must pass licensure exams and be

knowledgeable in anatomy, chemistry, restorative art, pathology, business, accounting, and some law

• More women are becoming funeral directors • Funeral homes must give full price disclosure • Must get written consents for embalming

• Typical service

• 20 to 40 minutes • $6,000-$8,000 cost • Music prelude, opening prayer, introductory remarks,

words from friends and family, clergy remarks, closing

Alternatives to Traditional Funerals • Memorial Service (less formal, more personal in design) • Green Funerals

• Buried in biodegradable wrap placed in woodlands or meadows

• Available U.S., more established in Europe • Virtual Memorials (on the internet)

• Tell the story of the person’s life (add photographs or videos)

• Guest book that others can sign • Most common – children who died of illness

Pre-Funeral Preparations

• Autopsy: Procedure to determine how and under what circumstances a person die by examining their body, organs, potential of toxins in blood. o Performed in suspicious or unexpected causes of

death o Not accepted by all religious traditions o Usually performed by a pathologist

Pre-Funeral Preparations

• Embalming: o Process of preserving the body by removing the

blood and replacing it with embalming fluids o Slows or halts decomposition. o Written consent from next of kin is required. o Conducted by certified embalmers in funeral

homes. o Required for a body to cross state lines. o Utilized by about 30% of Americans.

Spontaneous Memorials • A public, spontaneous response to a death, usually a

violent and unanticipated death • Usually at the site of the death • Usually occurs quickly after the death is announced in

the media • Leave candles, mementoes, cards • People often stay to reflect on the tragedy, and many will

return several times • No one is left out, all can participate

Examples of Abuse in the Funeral Process • Tri-State Crematory in Georgia dumped 334 bodies

while giving families cement dust instead of ashes • Tulane University’s School of Medicine sold bodies to the

U.S. Army for experiments with landmines • UCLA Medical School sold cadaver parts to a broker

who sold them to commercial biomedical corporations • Cadavers used as crash dummies in vehicle studies • Cases of body harvesting to brokers • Burial insurance industry overcharging and defrauding

black Americans

THE FUNERAL PROCESS

Module 4: Part 2

Christian Views on End of Life and Funeral Processes • Euthanasia not allowed in Roman

Catholicism or Orthodox Christians • Organ donation acceptable to most

denominations • Most permit cremation

Jewish Views • Do not believe in Euthanasia • Orthodox Jews do not permit autopsy or

cremation, some allow organ donation

Rituals surround Death in the Jewish Tradition • Burial preparation includes ritual washing of

the body, dressing in white clothes or shroud • Body is never left alone until burial occurs • Embalming is not permitted • Usually burial is within 24 hours of death • Seven days of mourning and attendance of

family members

Buddhist Rituals

• Usually use Cremation • Death practices vary depending on the

Buddhist tradition • Body left in place for as long as possible • Ritually washed by male family member • Body not left a lone prior to cremation • Cremation occurs after three days

Muslim Views • Do not allow cremation, usually not autopsy

unless absolutely necessary • Do not allow euthanasia

Burial Rituals in Islam • Muslims of the same gender handle the dead

body unless no one is available (usually direct family members)

• Ritual washing, perfuming and wrapping of the body

• Burial usually within 24 hours • Not buried in a coffin unless it is required by

law in the country of burial • Some prefer unmarked graves

Hindu Rituals • Family is consulted as to how the body should

be handled • Ritual washing and anointing, including trimming

hair, clean clothes • Funeral within 24 hours, body carried to the

funeral pyre where Hindu priests /senior family members conduct the funeral service

• Cremation performed to allow soul to make journey