Dying

Last updated

Dying is the final stage of life which will eventually lead to death. Diagnosing dying is a complex process of clinical decision-making, and most practice checklists facilitating this diagnosis are based on cancer diagnoses. [1]

Contents

Signs of dying

The National Cancer Institute in the United States advises that the presence of some of the following signs may indicate that death is approaching: [2] [3]

Cultural perspectives on dying

How humans understand and approach the process dying differs across cultures. [5] In some cultures, death is the complete termination of life. [5] In other cultures, death can include altered states of being, like sleep or illness. [5] In some traditions, death marks the transition into a different kind of existence, or involves a cyclic pattern of death and rebirth. [5] These cultural differences affect people's lifestyles, behaviors, and approach to death and dying. [5]

United States

In the United States, a pervasive "death-defying" culture leads to resistance against the process of dying. [5] Death and illness are often conceived as things to "fight against", [5] with conversations about death and dying considered morbid or taboo. Most people die in a hospital or nursing facility, with only around 30% dying at home. [6] As the United States is a culturally diverse nation, attitudes towards death and dying vary according to cultural and spiritual factors. [7]

China

In Chinese culture, death is viewed as the end of life — there is no afterlife — resulting in negative perceptions of dying. [8] These attitudes towards death and dying originate from the three dominant religions in China: Taoism, Buddhism, and Confucianism. [9]

South Pacific

In some cultures of the South Pacific, life is believed to leave a person's body when they are sick or asleep, making for multiple "deaths" in the span of one lifetime. [5]

Religious perspectives on dying

Christianity

In Christian belief, most people agree that believers will only experience death once; however, various traditions hold different beliefs about what happens during the intermediate state, the period between death and the universal resurrection. For many traditions, death is the separation of body and soul, so the soul continues to exist in a disembodied state. Other traditions believe that the soul and body are inseparable, meaning that the body's death renders the soul unconscious until the resurrection. Others believe that the spirit leaves the body to exist in heaven or hell. [5]

Islam

In Islamic belief, the time of death is predetermined, with dying therefore perceived as the will of Allah. Dying is therefore considered as something to be accepted, with Muslims regularly encouraged to reflect upon death and dying. [10] The majority of Muslims prefer to die at home, surrounded by their loved ones, with large numbers expected at the bedside of those who are dying. [11]

Hinduism

In Hinduism, people are believed to die and be reborn with a new identity. [5]

Buddhism

In Chinese Buddhism, it is said that dying patients will experience phases between the state of torment and the state of exultation, and that caretaker must help the dying patient remain in the state of exultation through Nianfo prayers. In some parts of Buddhism, the dead and living exist together, with the former having power and influence over the lives of the latter. [5]

Medicalization

Resuscitation

Resuscitation is the act of reviving of someone and is performed when someone is unconscious or dying. [12] Resuscitation is performed using a variety of techniques, of those the most common is Cardio Pulmonary Resuscitation (CPR). CPR is a procedure consisting of cycles of chest compressions and ventilation support with the goal of maintaining blood flow and oxygen to the vital organs of the body. [13] Defibrillation, or shock, is also provided following CPR in an attempt to jump start the heart. Emergency Medical Services (EMS) are often the first to administer CPR to patients outside of the hospital. Although EMS is not able to pronounce death, they are asked to determine the presence of clear signs of death and gauge whether CPR should be attempted or not. CPR is not indicated if the provider is at risk of harm or injury while attempting CPR, if clear signs of death are present (rigor mortis, dependent lividity, decapitation, transection, decomposition, etc.), or if the patient is exempt from resuscitation. Exemption is typically the case when the patient has an advanced directive, a Physician Orders for Life-Sustaining Treatment (POLST) form indicating that resuscitation is not desired, or a valid Do Not Attempt Resuscitation (DNAR) order. [14]

End-of-life care

End-of-life care is oriented towards a natural stage in the process of living, unlike other conditions. The National Hospice and Palliative Care Organization (NHPCO) states that hospice care or end-of-life care begins when curative treatments are no longer possible, and a person is diagnosed with a terminal illness with less than six months to live. [15] Hospice care involves palliative care aimed at providing at comfort for patients and support for loved ones. This process integrates medical care, pain management, as well as social and emotional support provided by social workers and other members of the healthcare team including family physicians, nurses, counselors, trained volunteers, and home health aides. [16] Hospice care is associated with enhanced symptom relief, facilitates achievement of end-of-life wishes, and results in higher quality of end-of-life care compared with standard care involving extensive hospitalization. [16]

Psychological adjustment processes

When a person realizes that their life is threatened by a fatal illness, they come to terms with it and with their approaching end. This confrontation has been described in diaries, autobiographies, medical reports, novels, and also in poetry. Since the middle of the 20th century, the "fight" against death has been researched in the social sciences on the basis of empirical data and field studies field research. The developed theories and models are intended to serve helpers in the accompaniment of terminally ill people above anything else.

The theories of dying describe psychosocial aspects of dying as well as models for the dying process. Particularly highlighted psychosocial aspects are: Total Pain (C. Saunders), Acceptance (J. M. Hinton, Kübler-Ross), Awareness/Insecurity (B.Glaser, A.Strauß), Response to Challenges (E.S.Shneidman), Appropriateness (A. D. Weisman), [17] Autonomy (H.Müller-Busch [18] ), Fear (R. Kastenbaum, [19] G.D.Borasio) and Ambivalence (E. Engelke [20] ).

Phase and stage models

There have been many phase and stage models for the course of dying developed from a psychological [21] and psychosocial perspective. A distinction is made between three and twelve phases that a dying person goes through. [22] [23] [24] [25] [26]

A more recently developed and revised phase model is the Illness Constellation Model, first published in 1991. [23] [24] The phases are associated with shock, dizziness, and uncertainty at the first symptoms and diagnosis; changing emotional states and thoughts, efforts to maintain control over one's own life; withdrawal, grief over lost abilities, and suffering from the imminent loss of one's own existence; finally psycho-physical decline.

The best known is the Five stages of Grief Model developed by Elisabeth Kübler-Ross, a Swiss-US psychiatrist. In her work, Kübler-Ross compiled various preexisting findings of Thanatology published by John Hinton, Cicely Saunders, Barney G. Glaser and Anselm L. Strauss and others. [27] Because of this, she brought the public's attention to it more than it previously received, which has continued to this day. She focused on the treatment of the dying, with grief and mourning, as well as with studies on death and near-death experiences. [28] The five stages in this model are the following: Denial and Isolation, Anger, Bargaining, Depression, and Consent. According to Kübler-Ross, hope is almost always present in each of the five phases, suggesting that the patients never completely give up and that hope must not be taken away from them. Loss of hope is soon followed by death, and the fear of death can only be overcome by everyone starting with themselves and accepting their own death, according to Kübler-Ross. From Kübler-Ross's research, psychiatrists have set new impulses for dealing with dying and grieving people. Her key message was that the people aiding must first clarify their own fears and life problems ("unfinished business") as far as possible and accept their own death before they can turn to the dying in a helpful way. The five phases of dying were extracted by Kübler-Ross from interviews of terminally ill people describing psychological adjustment processes in the dying process. The five phases are widely referred to, although Kübler-Ross herself critically questions the validity of her phase model several times. Some of her self-critiques include the following: The phases are not experienced in a fixed order one after the other, but they can alternate or repeat; some phases may not be experienced at all; a final acceptance of one's own dying may not take place in every case. [29] In end-of-life care, space is given to psychological conflict, but coping with the phases can rarely be influenced from the outside. [30]

In international research on dying, there are a number of scientifically based objections to the phase model and to models that describe dying in terms of staged behaviors in general. [31] [32] Above all, the naïve use of the phase model is viewed critically and even in specialist books, hope–a central aspect of the phase model for Kübler-Ross–is not mentioned. [33]

Influencing factors

The scientifically based criticism of phase models has led to forgoing defying the dying process in stages, and instead to elaborating on factors that influence the course of dying. Based on research findings from several sciences, Robert J. Kastenbaum says, "Individuality and universality combine in dying." [34] In Kastenbaum's model, individual and societal attitudes influence our dying and how we deal with knowledge about dying and death. Influencing factors are age, gender, interpersonal relationships, the type of illness, the environment in which treatment takes place, religion, and culture. This model is the personal reality of the dying person, where fear, refusal, and acceptance form the core of the dying person's confrontation with death. [35]

Ernst Engelke took up Kastenbaum's approach and developed it further with the thesis, "Just as each person's life is unique, so is their death unique. Nevertheless, there are similarities in the death of all people. According to this, all terminally ill people have in common that they are confronted with realizations, responsibilities, and constraints that are typical of dying." [36] For example, a characteristic realization is that the illness is threatening their life. Typical constraints result from the disease, therapies, and side effects. In Engelke's model, the personal and unique aspects of death result from the interaction of many factors in coping with the realizations, responsibilities, and constraints. Important factors include the following: the genetic make-up, personality, life experience, physical, psychological, social, financial, religious, and spiritual resources; the type, degree, and duration of the disease, the consequences and side effects of treatment, the quality of medical treatment and care, the material surroundings (i.e. furnishings of the apartment, clinic, home); and the expectations, norms, and behavior of relatives, carers, doctors and the public. According to Engelke, the complexity of dying and the uniqueness of each dying person creates guidelines for communication with dying people. [37]

Awareness

Along with medical professionals and relatives, sociologists and psychologists also engage in the question of whether it is ethical to inform terminally ill patients of the infaust prognosis, or the uncertain diagnosis. [38] In 1965, the sociologists Barney G. Glaser and Anselm Strauss published the results of empirical studies where they derived four different types of Awareness of dying patients: Closed Awareness, Suspected Awareness, Mutual Pretense Awareness, and Open Awareness. [39] In Closed Awareness, only relatives, caregivers, and medical professionals recognize the patient's condition; the patient themselves does not recognize his dying. In Suspected Awareness, the patient suspects what those around him know, but they are not told by relatives or medical professionals. In Mutual Pretense Awareness, all participants know about that the person is dying, but they behave as if they did not know. In Open Awareness, all participants behave according to their knowledge. [40]

The Hospice Movement in the United Kingdom in particular has since advocated for open, truthful and trustful interaction. [41] The situation does not become easier for all involved if difficult conversations are avoided; rather it intensifies and possibly leads to a disturbed relationship of trust between people, which makes further treatment more difficult or impossible. [42]

See also

Related Research Articles

<span class="mw-page-title-main">Cardiopulmonary resuscitation</span> Emergency procedure for cardiac arrest

Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation, or mouth to mouth in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. It is recommended for those who are unresponsive with no breathing or abnormal breathing, for example, agonal respirations.

Clinical death is the medical term for cessation of blood circulation and breathing, the two criteria necessary to sustain the lives of human beings and of many other organisms. It occurs when the heart stops beating in a regular rhythm, a condition called cardiac arrest. The term is also sometimes used in resuscitation research.

<span class="mw-page-title-main">Do not resuscitate</span> Legal order saying not to perform CPR if heart stops

A do-not-resuscitate order (DNR), also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), no code or allow natural death, is a medical order, written or oral depending on the jurisdiction, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Sometimes these decisions and the relevant documents also encompass decisions around other critical or life-prolonging medical interventions. The legal status and processes surrounding DNR orders vary in different polities. Most commonly, the order is placed by a physician based on a combination of medical judgement and patient involvement.

Palliative care is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses. Within the published literature, many definitions of palliative care exist. The World Health Organization (WHO) describes palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain, illnesses including other problems whether physical, psychosocial, and spiritual". In the past, palliative care was a disease specific approach, but today the WHO takes a broader patient-centered approach that suggests that the principles of palliative care should be applied as early as possible to any chronic and ultimately fatal illness. This shift was important because if a disease-oriented approach is followed, the needs and preferences of the patient are not fully met and aspects of care, such as pain, quality of life, and social support, as well as spiritual and emotional needs, fail to be addressed. Rather, a patient-centered model prioritizes relief of suffering and tailors care to increase the quality of life for terminally ill patients.

<span class="mw-page-title-main">Thanatology</span> Scientific study of death and its aspects

Thanatology is the scientific study of death and the losses brought about as a result. It investigates the mechanisms and forensic aspects of death, such as bodily changes that accompany death and the postmortem period, as well as wider psychological and social aspects related to death. It is primarily an interdisciplinary study offered as a course of study at numerous colleges and universities.

In medicine, specifically in end-of-life care, palliative sedation is the palliative practice of relieving distress in a terminally ill person in the last hours or days of a dying person's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route.

Terminal illness or end-stage disease is a disease that cannot be cured or adequately treated and is expected to result in the death of the patient. This term is more commonly used for progressive diseases such as cancer, dementia or advanced heart disease than for injury. In popular use, it indicates a disease that will progress until death with near absolute certainty, regardless of treatment. A patient who has such an illness may be referred to as a terminal patient, terminally ill or simply as being terminal. There is no standardized life expectancy for a patient to be considered terminal, although it is generally months or less. Life expectancy for terminal patients is a rough estimate given by the physician based on previous data and does not always reflect true longevity. An illness which is lifelong but not fatal is a chronic condition.

According to the model of the five stages of grief, those experiencing grief go through five emotions: denial, anger, bargaining, depression and acceptance. Although it is in common use, studies have not confirmed these stages, and the model has been criticized as outdated as well as unhelpful in explaining the grieving process.

<span class="mw-page-title-main">Elisabeth Kübler-Ross</span> Swiss-American psychiatrist (1926–2004)

Elisabeth Kübler-Ross was a Swiss-American psychiatrist, a pioneer in near-death studies, and author of the internationally best-selling book, On Death and Dying (1969), where she first discussed her theory of the five stages of death, also known as the "Kübler-Ross model".

Death education is education about death that focuses on the human and emotional aspects of death. Though it may include teaching on the biological aspects of death, teaching about coping with grief is a primary focus. The scientific study of death is known as thanatology. Thanatology stems from the Greek word thanatos, meaning death, and ology meaning a science or organized body of knowledge. A specialist in this field is a thanatologist.

<span class="mw-page-title-main">Ira Byock</span> American physician and author

Ira Robert Byock is an American physician, author, and advocate for palliative care. He is founder and chief medical officer of the Providence St. Joseph Health Institute for Human Caring in Torrance, California, and holds appointments as active emeritus professor of medicine and professor of community health and family medicine at the Geisel School of Medicine at Dartmouth College. He was director of palliative medicine at Dartmouth–Hitchcock Medical Center, from 2003–14, and associate director for patient and family-centered care at the affiliated Norris-Cotton Cancer Center.

In medicine, dysthanasia means "bad death" and is considered a common fault of modern medicine. Dysthanasia occurs when a person who is dying has their biological life extended through technological means without regard to the person's quality of life. Technologies such as an implantable cardioverter defibrillator, artificial ventilation, ventricular assist devices, and extracorporeal membrane oxygenation can extend the dying process. In some cases, cardiopulmonary resuscitation can be considered a form of dysthanasia.

End-of-life care (EOLC) refers to health care provided in the time leading up to a person's death. End-of-life care can be provided in the hours, days, or months before a person dies and encompasses care and support for a person's mental and emotional needs, physical comfort, spiritual needs, and practical tasks.

The Liverpool Care Pathway for the Dying Patient (LCP) was a care pathway in the United Kingdom covering palliative care options for patients in the final days or hours of life. It was developed to help doctors and nurses provide quality end-of-life care, to transfer quality end-of-life care from the hospice to hospital setting. The LCP is no longer in routine use after public concerns regarding its nature. Alternative methodologies for Advance care planning are now in place to ensure patients are able to have dignity in their final hours of life. Hospitals were also provided cash incentives to achieve targets for the number of patients placed on the LCP.

Rainbow Hospice and Palliative Care, founded in 1981, is one of the oldest and largest non-profit hospice and palliative care providers in Illinois.

<span class="mw-page-title-main">Hospice care in the United States</span>

In the United States, hospice care is a type and philosophy of end-of-life care which focuses on the palliation of a terminally ill patient's symptoms. These symptoms can be physical, emotional, spiritual or social in nature. The concept of hospice as a place to treat the incurably ill has been evolving since the 11th century. Hospice care was introduced to the United States in the 1970s in response to the work of Cicely Saunders in the United Kingdom. This part of health care has expanded as people face a variety of issues with terminal illness. In the United States, it is distinguished by extensive use of volunteers and a greater emphasis on the patient's psychological needs in coming to terms with dying.

<span class="mw-page-title-main">Hospice</span> Organization that cares for the dying or the incurably ill

Hospice care is a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life. Hospice care prioritizes comfort and quality of life by reducing pain and suffering. Hospice care provides an alternative to therapies focused on life-prolonging measures that may be arduous, likely to cause more symptoms, or are not aligned with a person's goals.

Sam Parnia is a British associate professor of Medicine at the NYU Langone Medical Center where he is also director of research into cardiopulmonary resuscitation. In the United Kingdom, he is director of the Human Consciousness Project at the University of Southampton. Parnia is known for his work on near-death experiences and cardiopulmonary resuscitation.

<span class="mw-page-title-main">M. R. Rajagopal</span> Indian palliative care physician (born 1947)

M. R. Rajagopal is an Indian palliative care physician (anesthesiologist) and professor referred to as the 'father of palliative care in India' in honour of his significant contribution to the palliative care scene in India.

Terminal lucidity is an unexpected return of consciousness, mental clarity or memory shortly before death in individuals with severe psychiatric or neurological disorders. It has been reported by physicians since the 19th century. Terminal lucidity is a narrower term than the phenomenon paradoxical lucidity where return of mental clarity can occur anytime. However, as of 2024, terminal lucidity is not considered a medical term and there is no official consensus on the identifying characteristics.

References

  1. Kennedy, Catriona; Brooks-Young, Patricia; Brunton Gray, Carol; Larkin, Phil; Connolly, Michael; Wilde-Larsson, Bodil; Larsson, Maria; Smith, Tracy; Chater, Susie (September 2014). "Diagnosing dying: an integrative literature review". BMJ Supportive & Palliative Care. 4 (3): 263–270. doi:10.1136/bmjspcare-2013-000621. ISSN   2045-435X. PMC   4145438 . PMID   24780536.
  2. "Physical Changes as You Near the End of Life". www.cancer.org. Retrieved 2020-04-30.
  3. "End-of-Life Care: Questions and Answers". NCI Factsheet. 30 October 2002.
  4. Linda LE, Ferris FD, von Gunten C. "The Last Hours of Living: Practical Advice for Clinicians". Medscape. Archived from the original on 28 January 2017. Retrieved 17 November 2017.
  5. 1 2 3 4 5 6 7 8 9 10 11 Gire, James (2014-12-01). "How Death Imitates Life: Cultural Influences on Conceptions of Death and Dying". Online Readings in Psychology and Culture. 6 (2). doi: 10.9707/2307-0919.1120 . ISSN   2307-0919.
  6. Cross, Sarah H.; Warraich, Haider J. (2019-12-12). "Changes in the Place of Death in the United States". New England Journal of Medicine. 381 (24): 2369–2370. doi: 10.1056/NEJMc1911892 . ISSN   0028-4793. PMID   31826345. S2CID   209330310.
  7. Kwak, Jennifer J. (2022-03-16). "Death attitudes among older Asian and Pacific Islander Americans: The role of religiosity, spirituality, and psychosocial health factors". Death Studies. 46 (3): 648–657. doi:10.1080/07481187.2020.1752853. ISSN   0748-1187. PMID   32324111. S2CID   216084601.
  8. Yu Xu (August 2007). "Death and Dying in the Chinese Culture: Implications for Health Care Practice". Home Health Care Management & Practice. 19 (5): 412–414. doi:10.1177/1084822307301306. ISSN   1084-8223. S2CID   208318522.
  9. "The Chinese Approach to Death and Dying". INELDA. 2017-06-23. Retrieved 2022-11-11.
  10. Sheikh, Aziz (March 1998). "Death and Dying—a Muslim Perspective". Journal of the Royal Society of Medicine. 91 (3): 138–140. doi:10.1177/014107689809100307. ISSN   0141-0768. PMC   1296563 . PMID   9659326.
  11. Tayeb, Mohamad A.; Al-Zamel, Ersan; Fareed, Muhammed M.; Abouellail, Hesham A. (2010). "A "good death": perspectives of Muslim patients and health care providers". Annals of Saudi Medicine. 30 (3): 215–221. doi: 10.4103/0256-4947.62836 . ISSN   0256-4947. PMC   2886872 . PMID   20427938.
  12. "resuscitation", The Free Dictionary, retrieved 2022-09-19
  13. "Cardiopulmonary resuscitation (CPR): First aid". Mayo Clinic. Retrieved 2022-09-19.
  14. Libby, Christopher; Skinner, Robert B.; Rawal, Amit R. (2022), "EMS Termination Of Resuscitation And Pronouncement of Death", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   31082157 , retrieved 2022-09-12
  15. Huffman, Jaime L.; Harmer, Bonnie (2022), "End of Life Care", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   31334996 , retrieved 2022-09-12
  16. 1 2 Tatum, Paul E. (November 2020). "End-of-Life Care: Hospice Care". FP Essentials. 498: 26–31. ISSN   2159-3000. PMID   33166104.
  17. Weisman A., On Dying and Denying, Behavioral Publications Inc., New York, pp. 36, 41, 1972.
  18. https://www.researchgate.net/profile/H-Christof-Mueller-Busch
  19. Horsley, Jo & Kastenbaum, Robert & Aisenberg, Ruth. (1973). The Psychology of Death. The American Journal of Nursing. 73. 1108. 10.2307/3422766.
  20. https://www.lovelybooks.de/autor/Ernst-Engelke/
  21. Erich Stern: Psychologie des Sterbens. In: Die Umschau. Band 37, 1933, S. 21–24.
  22. E. M. Pattison: The experience of dying. Englewood Cliffs 1977.
  23. 1 2 E. Kübler-Ross: Interviews mit Sterbenden. Kreuz, Stuttgart 1972.
  24. 1 2 A. D. Weisman: On Dying and Denying: a Psychiatric Study of Terminality. New York 1972.
  25. P. Sporken: Umgang mit Sterbenden. Medizinische und pastorale Aspekte der Sterbehilfe. Patmos Verlag, 1975.
  26. J. Morse, J. Johnson: Toward a theory of illness: The Illness Constellation Model. In: The illness experience: Dimensions of suffering. Newbury Park 1991.
  27. Ernst Engelke: Die Wahrheit über das Sterben: Wie wir besser damit umgehen. Rowohlt, Reinbek bei Hamburg 2015, ISBN 978-3-499-62938-9, S. 63–64.
  28. Video: Elisabeth Kübler-Ross über Nahtoderfahrungen (1981). retrieved 14 March 2014.
  29. J. Wittkowski: Zur Psychologie des Sterbens – oder: Was die zeitgenössische Psychologie über das Sterben weiß. In: F.-J. Bormann, G. D. Borasio (Hrsg.): Sterben. Dimensionen eines anthropologischen Grundphänomens. De Gruyter, Berlin 2012, S. 50–64.
  30. E. Albrecht, S. Roller: Terminalphase und Tod. In: Leitfaden Palliative Care. Palliativmedizin und Hospizbetreuung. Urban & Fischer, München 2010, S. 523.
  31. J. Wittkowski: Psychologe des Todes. Wissenschaftliche Buchgesellschaft, Darmstadt 1990, S. 117–140.
  32. N. Samarel: Der Sterbeprozess. In: J. Wittkowski (Hrsg.): Sterben, Tod und Trauer. Kohlhammer Stuttgart 2003, S. 122–151.
  33. C. Bausewein, S. Roller, R. Voltz: Leitfaden Palliativmedizin. Urban & Fischer, Jena 2004, S. 10.
  34. R. Kastenbaum (2007), Death, society, and human experience, New York: Routledge, pp. 126–149
  35. R. Kastenbaum: Death, society, and human experience. Routledge, New York 2007, ISBN 978-0-205-00108-8.
  36. E. Engelke: Die Wahrheit über das Sterben. Wie wir besser damit umgehen. Rowohlt Taschenbuch Verlag, Reinbek bei Hamburg 2015, ISBN 978-3-499-62938-9.
  37. E. Engelke: Gegen die Einsamkeit Sterbenskranker. Wie Kommunikation gelingen kann. Lambertus, Freiburg i. Br. 2012, S. 209–341.
  38. https://medical-dictionary.thefreedictionary.com/infaust#:~:text=adjective%20Referring%20to%20a%20clinical,an%20uncertain%2C%20often%20poor%20prognosis.
  39. https://groundedtheoryreview.com/2015/12/19/awareness-of-dying-remains-relevant-after-fifty-years/#:~:text=What%20emerged%20during%20their%20investigation,Glaser%20and%20Strauss%20(1965).
  40. Barney G. Glaser, Anselm Strauss: Awareness of Dying. Aldine Pub. Co., Chicago 1965.
  41. https://www.mariecurie.org.uk/blog/what-is-the-hospice-movement/208684#:~:text=Good%20hospice%20care%20helps%20people,matter%20what%20prognosis%20you%20have.
  42. A. Lübbe, I. Lübbe: Wahrheit und Wahrhaftigkeit beim Umgang mit terminal Kranken. In: Zeitschrift für Palliativmedizin. 3/2012, S. 121.