• Death has biological, social, cultural, historical, religious, legal, psychological, developmental, and ethical aspects.

Guidepost 1: How do attitudes and customs concerning death differ across cultures?

• Customs surrounding death and mourning vary greatly from one culture to another, depending on the society's view of the nature and consequences of death. Some modern customs have evolved from ancient beliefs and practices.

Guidepost 2: What are the implications of the "mortality revolution," and how does it affect care of the dying?

• Death rates dropped drastically during the twentieth century, especially in developed countries.
• Today three-quarters of deaths in the United States occur among the elderly, and the top causes of death are diseases that primarily affect older adults.
• As death became primarily a phenomenon of late adulthood, it became largely "invisible," and care of the dying took place in isolation, by professionals.
• There is now an upsurge of interest in understanding and dealing realistically and compassionately with death. Examples of this tendency are a growing interest in thanatology and increasing emphasis on hospice care and palliative care.

Guidepost 3: How do people change as they confront their own death?

• People often undergo cognitive and functional declines shortly before death.
• Some people who come close to dying have "near-death" experiences.
• Elisabeth Kübler-Ross proposed five stages in coming to terms with dying: denial, anger, bargaining, depression, and acceptance. These stages, and their sequence, are not universal.

Guidepost 4: Is there a normal pattern of grieving?

• There is no universal pattern of grief.
• The most widely studied pattern of grief work moves from shock and disbelief to preoccupation with the memory of the dead person and finally to resolution. Research has found several variations, including high to low distress, no intense distress, and prolonged distress.
• For some people who have great difficulty adjusting to a loss, grief therapy may be indicated.

Guidepost 5: How do attitudes and understandings about death and bereavement differ across the life span?

• Before ages 5 to 7, children do not understand that death is irreversible, universal, inevitable, and nonfunctional. Young children can better understand death if it is part of their own experience. Although children experience grief, as adults do, there are age-related reactions based on cognitive and emotional development.
• Although adolescents generally do not think much about death, violence and the threat of death are part of some adolescents' daily life. Adolescents tend to take needless risks.
• Realization and acceptance of the inevitability of death increases throughout adulthood.

Guidepost 6: What special challenges are involved in surviving a spouse, a parent, or a child, or in mourning a miscarriage?

• Women are more likely to be widowed, and widowed younger, than men, and may experience widowhood somewhat differently. Coping skills are more important than age in determining how widowed persons adjust. For some people, widowhood can ultimately become a positive developmental experience.
• Today, loss of parents often occurs in middle age. Death of a parent can precipitate changes in the self and in relationships with others.
• The loss of a child can be especially difficult because it is no longer normative. Often such a loss weakens or destroys the parents' marriage.
• Miscarriage is not generally considered a significant loss in U.S. society. People are left to deal with a miscarriage in their own way.

Guidepost 7: How common is suicide?

• Although suicide is no longer illegal in modern societies, there is still a stigma attached to it. Some people maintain a "right to die," especially for people with long-term degenerative illness.
• Suicide is the eleventh leading cause of death in the United States, lower than in many other countries. The number of suicides is probably underestimated.
• Suicide rates tend to rise with age and are more common among men than among women, though women are more likely to attempt suicide. The highest rate of suicide in the United States is among elderly white men. It is often related to depression, isolation, and debilitating ailments.

Guidepost 8: Why are attitudes toward euthanasia ("mercy killing") and assisted suicide changing, and what concerns do these practices raise?

• Euthanasia and assisted suicide involve controversial issues concerning the "right to die," protection from abuse, and medical ethics.
• To avoid unnecessary suffering through artificial prolongation of life, passive euthanasia is generally permitted with the patient's consent or with advance directives. However, such directives are not consistently followed. Most hospitals now have ethics committees to deal with decisions about end-of-life care.
• Active euthanasia and assisted suicide are generally illegal, but public support for physician aid in dying has increased. The state of Oregon has a law permitting physician assisted suicide for the terminally ill. The Netherlands and Belgium have legalized both euthanasia and assisted suicide.
• The aid-in-dying controversy has focused more attention on the need for better palliative care and understanding of patients' state of mind.

Guidepost 9: How can people overcome fear of dying and come to terms with death?

• The more meaning and purpose people find in their lives, the less they tend to fear death.
• Life review can help people prepare for death and give them a last chance to complete unfinished tasks.
• Even dying can be a developmental experience.