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Talking about death never has been an easy matter. Through historical analysis, one realizes that the fear of death was always present, but with different ways of dealing with it. Today we realize the institutionalization of the dying process, as well as the feelings manifestation. After the Psychiatric Reform, also emerged the Institutions of support in Mental Health, such as Outpatient Mental Health and Psychosocial Care Centers (CAPS), which aim to promote and expand health care to the population in general, in order to promoting wellness and avoid the emergence of chronicity of psychopathology. In these institutions, two specialties professionals stand out in joint action; psychologists and psychiatrists. This mutual action is interesting because it allows a comprehensive view of the subject, in their physical and psychological behavior aspects. Thus, the aim of this study is to understand the presence of death in the outpatient work through the perception of the professionals who work in these places. For this, a qualitative and exploratory study was conducted through semi-structured interviews with guiding principles. For data analysis, was employed content analysis, with emerging categories from the speeches. Among the results, was found several ways of encounter the issue at the clinic, they are: bereavement, complicated grief, preparation for an upcoming death through illness or old age, death and suicidal ideation in life, represented by loss of subjectivity. Among these ways, suicide presented special mention, being described as the most complex due to the large responsibility that the professional has in conducting such cases. Furthermore, was possible to explore the understanding of the professionals in this demand and what were the everyday practices of coping. The study findings are presented in three articles, divided by the subject to which they relate. / Falar sobre morte nunca foi assunto fácil. Através de análise histórica, percebe-se que o temor da morte sempre esteve presente, porém com diversas formas de lidar com ele. Hoje se percebe a institucionalização do processo de morrer, assim como da manifestação de sentimentos. Após a Reforma Psiquiátrica, surgiram também Instituições de amparo em Saúde Mental, como Ambulatórios de Saúde Mental e Centros de Atenção Psicossocial (CAPS), que objetivam promover saúde e ampliar atendimento à população em geral para gerar bem estar e evitar cronificação de psicopatologias. Nessas instituições, duas especialidades de profissionais destacam-se na atuação conjunta, sendo eles psicólogos e psiquiatras. Essa ação conjunta é interessante por possibilitar uma visão integral do sujeito, em seus aspectos físicos e psicológicos do comportamento. Assim, o presente trabalho objetiva compreender a presença da morte no trabalho ambulatorial através da percepção destes profissionais que atuam nestes locais. Para tanto, foi realizado um estudo qualitativo e de cunho exploratório através de entrevistas semiestruturadas com eixos norteadores. Para interpretação dos dados, utilizou-se de análise de conteúdo, com categorias emergentes das falas. Entre os resultados, encontrou-se diversas maneiras de deparar-se com o tema na clínica, sendo elas: luto, luto cronificado, preparação para uma morte próxima através de doença ou velhice, ideação suicida e morte em vida, representada pela perda da subjetividade. Entre essas maneiras, o suicídio apresentou especial destaque, sendo descrito como o mais complexo em função da grande responsabilidade que o profissional tem na condução de casos desta natureza. Ainda, pôde-se explorar o entendimento dos profissionais frente à essa demanda e qual eram as práticas corriqueiras de enfrentamento. Os achados do estudo estão apresentados em três artigos, divididos pelo assunto a que se referem.

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京都大学 / 新制・課程博士 / 博士(理学) / 甲第24183号 / 理博第4874号 / 新制||理||1697(附属図書館) / 京都大学大学院理学研究科生物科学専攻 / (主査)准教授 足立 幾磨, 准教授 Huffman Michael Alan, 教授 今井 啓雄 / 学位規則第4条第1項該当 / Doctor of Science / Kyoto University / DFAM

A morte é inevitável, porém, pouco se comenta em relação aos seus conceitos, sentimentos, particularmente em idosos para os quais ela está mais próxima. Avaliamos o conceito de morte/morrer em idosos asilados (IA, N=27) e não asilados (INA, N=25). Foram aplicados 4 questionários: sobre religiosidade (DUREL), estado mental (MEEM) e depressão (GDS) e construído um questionário sobre conceito morte/morrer com questões fechadas e abertas. Houve predominância feminina, branca, católica de baixo grau de escolaridade. Não houve diferenças em relação à depressão, religiosidade e na maioria das questões sobre morte/morrer. Porém, os IA apresentaram maior idade, menor temor da maneira como vão morrer (p=0,046), creram ser menos possível ser educado para a morte (p=0,02), mostraram indiferença ao melhor local para morrer (p=0,005), acreditaram que hoje se morre pior em relação a gerações passadas (p=0,048) enquanto os INAs apresentaram tendência à escolha do hospital como local para morrer (p=0,063).As questões abertas foram úteis nas interpretações dos dados. As análises de confiabilidade permitiram diminuição de 40% do questionário original. Os resultados confirmam a dificuldade de instrumentos para avaliar amplamente o conceito morte morrer e que o asilamento em idosos não alterou a maioria dos conceitos sobre o tema / Death is inevitable, but little is said about its concept, how people feel about it, particularly the elderly, for whom death is more impending. We assessed the concept of death and dying among institutionalized (IE, N=27) and non-institutionalized elders (NIE, N=25).Four questionnaires were conducted: on religion (DUREL), mental status (MEEM), depression (GDS) and on their concept of death and dying, this one comprising open and close questions. The interviewees were predominantly white, catholic, and female with low formal education level. No differences were observed regarding depression issues and religiosity, and among most of the answers related to death and dying. However, the IE group comprised older individuals, who believed it was less possible to be educated about death (p=0.02), were indifferent regarding their dying place (p=0.005), were less fearful of the manner in which death will occur(p=0.046),and thought that people today die in worse ways than previous generations did (p=0.048);while most of the NIE individuals tended to choose hospitals as their dying place (p=0.063).Open questions were useful when interpreting data. Reliability analysis allowed the original questionnaire to be trimmed down in 40%. The results confirm how difficult it is to thoroughly assess the concept of death and dying, and that being institutionalized does not affect the overall concept of death and dying among this population

The central aim of this study was to explore the meaning of death as both a literal and an imaginative reality, and to elucidate the fundamental tensions between these meanings of death in modern existence. Recognition was given to the need for a poetic rather than a scientific approach to thanatology, and an epistemological foundation for a poetics of death was sought in the tradition of gnosis. Theoretically, the study was grounded in the analytical psychology of C.G. Jung. It was argued that despite Jung's erratic allegiance to a Cartesian ontology and epistemology, his approach to death was nevertheless fundamentally poetic. The poetic parameters of death and dying were explored in the context of Jung's understanding of the dialectical tension between the ego and the self, and it was concluded that while death represents an opening to the imaginative possibilities of existence, these potentialities can come to the fore only when there is a corresponding willingness to die. In these terms, it was concluded that the tension between life and death forms a pivotal dynamic of human existence. These considerations led to the Question of whether the poetic parameters of death and dying are applicable to the encounter with death as a concrete actuality. It was hypothesised that the approach of death would be met at two levels of reality, that of the ego and that of the self. The expectation was that while death would be seen as a literal ending from the perspective of the former, it may represent the fulfilment of Being from the viewpoint of the self. It was also assumed that the tension between these images of death would be mediated by way of archetypal symbols, which represent the bearers of gnosis in modern culture. To address these issues at an empirical level, a hermeneutically grounded thematic analysis of 108 dreams reported by dying persons was undertaken. Twenty initial themes emerged from the data. Each of these themes was in turn elucidated by way of Jung's method of amplification. This exercise yielded five concise themes, these being (a) death, (b) transformation, (c) the self (d) the Feminine, and (e) the Masculine. It was concluded that dreams manifesting during the dying process reveal a fundamental tension between literal and metaphoric possibilities of death. Dream symbols were also found to mediate between this tension, and to orchestrate the individuation process. It was concluded that in the context of dying, dreams may reflect and facilitate the emergence of a meaningful gnosis of death. The clinical implications of these findings were onsidered, and indications for further research were provided.

A morte é inevitável, porém, pouco se comenta em relação aos seus conceitos, sentimentos, particularmente em idosos para os quais ela está mais próxima. Avaliamos o conceito de morte/morrer em idosos asilados (IA, N=27) e não asilados (INA, N=25). Foram aplicados 4 questionários: sobre religiosidade (DUREL), estado mental (MEEM) e depressão (GDS) e construído um questionário sobre conceito morte/morrer com questões fechadas e abertas. Houve predominância feminina, branca, católica de baixo grau de escolaridade. Não houve diferenças em relação à depressão, religiosidade e na maioria das questões sobre morte/morrer. Porém, os IA apresentaram maior idade, menor temor da maneira como vão morrer (p=0,046), creram ser menos possível ser educado para a morte (p=0,02), mostraram indiferença ao melhor local para morrer (p=0,005), acreditaram que hoje se morre pior em relação a gerações passadas (p=0,048) enquanto os INAs apresentaram tendência à escolha do hospital como local para morrer (p=0,063).As questões abertas foram úteis nas interpretações dos dados. As análises de confiabilidade permitiram diminuição de 40% do questionário original. Os resultados confirmam a dificuldade de instrumentos para avaliar amplamente o conceito morte morrer e que o asilamento em idosos não alterou a maioria dos conceitos sobre o tema / Death is inevitable, but little is said about its concept, how people feel about it, particularly the elderly, for whom death is more impending. We assessed the concept of death and dying among institutionalized (IE, N=27) and non-institutionalized elders (NIE, N=25).Four questionnaires were conducted: on religion (DUREL), mental status (MEEM), depression (GDS) and on their concept of death and dying, this one comprising open and close questions. The interviewees were predominantly white, catholic, and female with low formal education level. No differences were observed regarding depression issues and religiosity, and among most of the answers related to death and dying. However, the IE group comprised older individuals, who believed it was less possible to be educated about death (p=0.02), were indifferent regarding their dying place (p=0.005), were less fearful of the manner in which death will occur(p=0.046),and thought that people today die in worse ways than previous generations did (p=0.048);while most of the NIE individuals tended to choose hospitals as their dying place (p=0.063).Open questions were useful when interpreting data. Reliability analysis allowed the original questionnaire to be trimmed down in 40%. The results confirm how difficult it is to thoroughly assess the concept of death and dying, and that being institutionalized does not affect the overall concept of death and dying among this population

No / Despite advances in technology and medicine, death itself remains an immutable certainty. Indeed, the acceptance and understanding of our mortality are among the enduring metaphysical challenges that have confronted human beings from the beginning of time. How have we sought to cope with the inevitability of our mortality? How do various cultural and social representations of mortality shape and influence the way in which we understand and approach death? To what extent do personal beliefs and convictions about the meaning of life or the notion of an afterlife affect how we perceive and experience the process of death and dying? Steve Paulson, executive producer and host of To the Best of Our Knowledge, moderated a discussion on death, dying, and what lies beyond that included psychologist Lani Leary, professor of philosophy and religion Jeffrey J. Kripal, and sociologist Allan Kellehear. The following is an edited transcript of the discussion that occurred February 5, 7:00-8:30 pm, at the New York Academy of Sciences in New York City.

Dilemmas in thanatology in the 21st century In the thesis "Dilemmas in thanatology in the 21st century" I focused on the definition of the contradictory questions about the end of human life. I found that most of the respondents of different age groups, who were involved in the care process and responded to the questionnaire, are acquainted with the issue of thanatology. They assess this issue as emotionally challenging, difficult and professionally untreated. In addition, I investigated the needs of helping professions in the issue of communication barriers in the topic of death and dying. I came to the conclusion that communication on this subject is displaced, missing training and there is a lack of the literature on this topic. Due to the unrepresentativeness of the survey I assess the result obtained only as the orientation indicator according to the issue under the investigation. This result rather opens up further contradictory questions in the thanatology.

Objetivo: A morte, que pode ainda ser considerada um tema tabu, e como os profissionais da saúde lidam com ela é algo a ser explorado neste estudo que o trata através de uma investigação com entrevistas à profissionais da medicina e enfermagem das Unidades de Terapia Intensiva (UTI) de um hospital universitário terciário e quaternário de São Paulo com o objetivo de apurar a visão da morte e do morrer face às atitudes propostas pela Dra. Elisabeth Kubler-Ross. Métodos: A metodologia se baseou em uma análise qualitativa de conteúdo dos dados apurados. Foram entrevistados 51 sujeitos dentre os quais 12 que não desejaram participar do estudo alegando não querer falar sobre morte. A pesquisa transcorreu entre os meses de outubro à dezembro de 2011 nas dependências das UTIs e foi previamente aprovada pelo Comitê de Ética em Pesquisa com Humanos. Também foram apurados dados sociodemográficos como sexo, idade, tempo de trabalho em UTI, se o entrevistado segue alguma filosofia religiosa e se tem algum conhecimento em cuidados paliativos. Na entrevista buscou-se detalhar a visão da morte dos profissionais segundo o que pensam sobre morte, como lidam com a morte, se gostariam de fazer ou dizer algo para quem está morrendo, sentem-se influenciados em sua vida pessoal pelo fato de trabalharem com morte, se vêem algum ponto positivo na morte, se conseguem definir a morte através de uma palavra e se já haviam conversado sobre morte. As entrevistas eram gravadas e posteriormente transcritas. Resultados: Nos resultados, constatou-se que esses profissionais já tinham uma considerável experiência em anos de trabalho em UTI e apresentam conformidade com as atitudes propostas pela Dra. Ross de negação, raiva, barganha, depressão e principalmente a aceitação. Também verificou-se que esses profissionais sentem-se influenciados pela presença da morte no seu cotidiano e carecem de maior preparo para o lidar com a morte. Conclusão: Concluiu-se que é de grande valia poder detalhar como o profissional da saúde se comporta face a morte, pois há um déficit em ouvi-los e traduzir seus sentimentos e percepções sobre a morte, fato este que pode concorrer com a humanização dos atendimentos, gerando angústias e fomentando o despreparo já existente / Purpose: Death, which can still be considered a taboo topic, and how health professionals deal with it is something to be explored in this study that comes through an investigation with interviews with medical professionals and nursing of Intensive Care Units (ICU ) of a tertiary and quaternary university hospital in São Paulo in order to establish the vision of death and dying in the face of attitudes proposed by Dr. Elisabeth Kubler-Ross. Methods: The methodology was based on a qualitative analysis of data collected. Fifty-one subjects were interviewed of whom 12 did not wish to participate in the study claimed they did not want to talk about death. The research took place from the months of October to December 2011 on the premises of ICU\'s and was approved by the Ethics in Human Research committee. Sociodemographic data were also counted as also sex, age, time service in ICU, if the respondent follow any religious philosophy and if one has some knowledge in palliative care. In the interview we sought to refine the vision of death according to what the professionals think about death, how they deal with death, if they would do or say something to the dying, if they feel influenced in their personal life by the fact that work with death if they see a positive point of death, if death can be defined through a word and if they had talked about death. The interviews were taped and later transcribed. Results: In the results, it was found that these professionals have had considerable experience in years of work in the ICU and are in agreement with the attitudes proposed by Dr. Ross of denial, anger, bargaining, depression and specially acceptance. Also it was found that these professionals feel influenced by the presence of death in their daily lives and need better preparation for dealing with death. Conclusion: It was concluded that it is of great value to be able to detail how the health professional behaves in the face of death, because there is a deficit in hearing them and translate their feelings and perceptions about death, a fact that can compete with the humanization of care, generating anxieties and boosting existing unpreparedness