1)Identify cultural perspectives on death

2)Discuss the roles of all parties involved in declarations of death and withdrawal of care

3)Identify differences between DNI and DNR

4)Identify elements of a health care proxy

5)Identify the differences between a health care proxy, a living will, and a durable power of attorney

1. In some cultures, people believe that the spirit of someone who has died directly influences the living family members. The family members are comforted by the belief that their loved one is watching over them. In general, beliefs about the meaning of death help people make sense of it and cope with its mystery. Some cultures expect a dignified and quiet response to loss while in other societies — mourners are expected to openly display their raw emotions. Emotions in grief, too, may vary between cultures. Some cultures expect feelings of loneliness or sadness while in other cultures, persons may respond with anger or rage. In each culture, death is associated with rituals and customs to help people with the grieving process. Rituals offer people ways to process and express their grief. They also provide ways for the community to support the bereaved. A person who is bereaved is in a period of grief and mourning after a loss. Death can create a sense of chaos and confusion. Rituals and customs provide a sense of routine and normalcy. They provide a set of directions that help structure the time surrounding death. Also, they direct people's roles during this time. Rituals and customs can help address:

• How people care for people as they approach death. This includes who is present and what ceremonies are performed at the moments before and after death.
• How a person's body is handled after death. This includes how the person's body is cleansed and dressed, who handles the body, and whether the body is buried or cremated.
• Whether grief is expressed quietly and privately or loudly and publicly. This includes whether public crying or wailing is appropriate.
• Whether people of different genders or ages grieve differently.
• What rituals people perform after death and who is included in these rituals.

2. Legally, you are not dead until someone says you are dead. You can be pronounced or declared dead. Each state in the USA has its own statutes that cover this. Typically a doctor or nurse can pronounce, and everyone else (police officers, EMT's, firefighters) will declare death. When a person dies, a doctor must confirm the death and issue a Medical Certificate Cause of Death. The doctor, executor, next of kin, relative or funeral director must then register the certificate with the NSW Registry of Births, Deaths and Marriages within seven days. A decision to withhold or withdraw life- sustaining treatment is a common feature of medical practice when caring for people who are approaching the end of life. 2. A person who has capacity can lawfully refuse treatment even if that treatment is needed to keep them alive. In general, treatment is withdrawn when death is felt to be inevitable despite continued treatment. This would typically be when dysfunction in three or more organ systems persists or worsens despite active treatment or in cases such as multiple organ failure in patients with failed bone marrow transplantation. When an intervention no longer helps to achieve the patient's goals for care or desired quality of life, it is ethically appropriate for physicians to withdraw it.

3. DNR means that no CPR (chest compressions, cardiac drugs, or placement of a breathing tube) will be performed. A DNI or "Do Not Intubate" order means that chest compressions and cardiac drugs may be used, but no breathing tube will be placed. When you request a Do Not Resuscitate (DNR) order, your doctor may ask you whether or not you also want a Do Not Intubate (DNI) order. The two are separate because you can have trouble breathing before your heartbeat or breathing stops. If your breathing problems continue, your heart or lungs may go into full arrest.

4. A health care proxy is a document that allows you to appoint another person(s) as your health care agent to make health care decisions on your behalf if you are no longer able to do so. You may give your health care agent authority to make decisions for you in all medical situations if you cannot speak for yourself. While living will is a written, legal document that spells out medical treatments you would and would not want to be used to keep you alive, as well as your preferences for other medical decisions, such as pain management or organ donation. In determining your wishes, think about your values. And durable powers of attorney help you plan for medical emergencies and declines in mental functioning and can ensure that your finances are taken care of. Having these documents in place helps eliminate confusion and uncertainty when family members have to make tough medical decisions.