Death is the inevitable conclusion of life, and we all experience death in a variety ways, but most of us try not to think about how and when we will die. End-of-life experiences are diverse and a deeply personal experience heavily influenced by the individuals culture, spirituality, and personal philosophy. This means that end-of-life care can be difficult to plan for the practicing nurse as each patient and family will have differing approaches to death.
There are however many changes that develop leading up to death. Sociologist David Sudnow made an influential proposal in his 1967 book Passing on: The Social Organisation of Dying; that a dying person may move through four types of death: social, psychological, biological and physiological death. This proposal has persisted and continues to be one of the underpin observations of withdrawal.
Social death refers to the persons gradual withdrawal from society. This can manifest in a variety of ways such as skipping appointments, avoiding social obligations, preferring to stay home than go out. Social withdrawal represents the symbolic death of of the person in relation to the world they have known. It is typically characterised as both the individual and those who know them drifting away from one another.
Psychological death refers to the metaphorical death of the underlying aspects o the dying person’s personality. Regression and varying degrees of dependency may occur as their illness progresses. The dying person will experience grief over losses, both physical and symbolic which in turn leads to psychological death.
Biochemical changes can occur within the body, usually brought on by medications and other pathophysiological changes due to illness. This can lead to changes in personality, mood and temperament which in turn causes changes in relationships resulting in isolation and invalidation. Rando (1984) suggests that this is the point where ‘the individual, as others know them, dies’.
Biological death is the scientific process of dying, and refers to a medical criteria that determines when the organism as a human entity ceases to exist.
The physiological changes that occur as the person approaches death vary greatly depending on the disease processes taking place, and often their complex interactions.
The leading causes of death in Australia for example are consistently cardiovascular and cerebrovascular disease, which are for the most part, preventable. But this data also indicates that the majority of deaths were also predictable. Through a thorough understanding of these disease processes, we can also predict the likely end-of-life path the person may experience and can plan and prepare them accordingly.
Physiological death refers to the complete cessation of all physiological processes of the body. It is important to differentiate between the physiological death and the medical definition of death, where the person is considered dead upon cessation of vital body functions, notably respirations and cardiac function.
Physiological death may occur some time after the person is declared dead as various body systems continue physiological processes until there is insufficient energy supplies, making further biochemical processes impossible.
Death is an inevitable fact of life, and although the individual experience varies, Sudnow’s four types of death have been adopted and persisted as the best model for the universal human death experience.