CONTEXTUALIZING
DEATH
Sonya Merrill, MD, PhD
Presbyterian Hospital of Dallas
September 7, 2005
OUTLINE
Death in the Context of:





Two ancient cultures
Four major world religions
Modern medicine
Society
The individual
Ancient Cultures
Egypt
Mesopotamia
Ancient Egypt
ANCIENT EGYPT
General Principles



Preoccupation with life and desire to “continue
living” after death
Afterlife resembles an improved earthly life
Continuing bodily existence:




mummification
attempts to recover bodies
fear of being eaten by animals
“Ideal” life span: 100 years
ANCIENT EGYPT
The Soul




Ba: the soul which animates the body, represented as
a bird flying away at the time of death
Akh: the spirit which survives death and which can
be good or evil, equipped with “spells” that are
useful after death
Ka: represented by a person’s image or statue and
thought to be a “protecting genius” after death
Suyt: a person’s shadow
ANCIENT EGYPT
The Body and its Preservation


Mummification: removal of decay-prone viscera
enabling preservation of majority of body parts;
process lasting 30-200 days
Step 1: Removal of entrails through left-sided thoracic
incision and storage in canopic jars bearing images of
the sons of the god, Horus




Liver (human son, Imesty)
Lungs (ape son, Hapy)
Stomach (jackal son, Duamutef)
Intestines (hawk son, Qebekhsenuef)
ANCIENT EGYPT
Canopic Jars
ANCIENT EGYPT
The Body and Its Preservation

Step 2: Removal of other organs





Heart: “seat of intelligence” so after removal, wrapped in linen
and replaced/sewn into chest cavity
Brain: not always removed as not deemed very important; when
removed, long hooked rods inserted into nostrils to snag tissue
Step 3: Application of natron (natural desiccant)
Step 4: Complete drainage of all bodily fluids
Step 5: Wrapping of body in yards of linen
ANCIENT EGYPT
The Body and Its Burial



The Opening of the Mouth ceremony: eyes, ears, nostrils
and mouth touched to symbolize opening and person’s
revival
Tombs: contained biographical information to preserve
occupant’s name and reputation; varied according to
importance of deceased
VIP burial arrangements:



Old Kingdom—wooden coffin inside stone sarcophagus
Middle Kingdom—human-shaped wooden coffin with mask over
mummy’s head inside stone sarcophagus
New Kingdom—elaborately painted anthropoid nested coffins, e.g.,
Tutankhamun’s 3 nested coffins
ANCIENT EGYPT
The Body and Its Burial
ANCIENT EGYPT
Afterlife: The Rough Guide

How to get there: by boat, sailing on a day-night
journey with the Sun God

navigate using basic spells from funerary texts left near the
body
ANCIENT EGYPT
Afterlife: The Rough Guide

Where to go when you arrive:
 Field of Offerings: a land on
the western horizon where
the deceased work in fields
and orchards to harvest
offerings for Osiris
 Paradise: where the
deceased reaps the fruits of
his own labor and enjoys a
blissful existence
ANCIENT EGYPT
Afterlife: The Rough Guide
 What



to pack:
Deceased require basic provisions to survive in
the afterlife
Initially, basic provisions (bread, beer, meat, wine,
linens) were placed in tombs
Later, models of provisions were deposited to
guarantee that supplies would last forever
ANCIENT EGYPT
Afterlife: The Rough Guide

Traveling companions:

Models of servants
included for purpose of
eternally producing
necessary supplies
Ancient Mesopotamia
ANCIENT MESOPOTAMIA
General Principles

Death is inevitable: “when the gods created
men, they set aside death for mankind and
kept eternal life in their own hands”

The ideal death: surrounded by family and
friends while lying on a special funerary bed
with a chair on the left serving as a seat for
the soul after its release from the body
ANCIENT MESOPOTAMIA
General Principles

Euphemism: speaking of “death” summons it, so
instead:


“to cross the Khubur,” “to go up to heaven,” “to go to one’s
fate,” “to be invited by one’s gods,” “to come to land on
one’s mountain,” “to go on the road of one’s forefathers”
Gradual process: rather than instantaneous end to
earthly existence



Individual ancestor is dependent on his descendents’
offerings
After several generations, ancestral spirits are collectivized
Finally, individual is annihilated and recycled into a new
soul
ANCIENT MESOPOTAMIA
The Soul




Etemmu: ghost associated with physical remains
Napistu: life force or “breath of life”
Zaqiqu: birdlike spirit able to fly and slip through
small spaces, associated with dreaming as it can
leave the body during sleep
Etemmu and zaqiqu descend with the body to the
netherworld at death; if the body is destroyed,
etemmu is also destroyed, leaving behind only zaqiqu
ANCIENT MESOPOTAMIA
The Body and Its Burial

Preparation: ceremonial washing, tying mouth shut,
perfuming, dressing in clean clothes

Public viewing: before the funeral

Burial: in the ground in a coffin, sarcophagus or tomb


Elites were buried in vaults below their houses or palaces while
others were buried in public cemeteries
Last rites: burnt offering

When a king died, his throne, table, weapon and scepter were
burned
ANCIENT MESOPOTAMIA
Funeral Customs





Mourning rituals lasting up to 7 days
Family and close friends expected to participate; in the
case of royalty, the entire population must mourn
Professional mourners sometimes employed
Funeral laments express mourners’ grief and eulogize
the deceased
Physical displays of grief: wearing plain clothes,
tearing clothes, wearing sackcloth, not bathing or
grooming, fasting
ANCIENT MESOPOTAMIA
Afterlife: The Rough Guide



Where: underground
Climate: dark, damp and dreary
How to get there: cross demon-infested lands, cross Khubur
River with the aid of its guardian god, gain entry through 7
gates to the city of the netherworld with its gatekeeper’s
permission
ANCIENT MESOPOTAMIA
Afterlife: The Rough Guide

Your hosts: meet the royal couple, Nergal and
Ereshkigal, and their courtiers who:



welcome the dead
instruct them in the local rules
show them to their lodgings in the netherworld (size
and grandeur do not correlate with the deceased’s
earthly behavior)
ANCIENT MESOPOTAMIA
Afterlife: The Rough Guide

How to pack: take as many personal items as you can afford



Travel provisions for the journey: food and sandals (or a chariot, if you
were wealthy)
Things you might need when you arrive: food, weapons, toiletries,
jewelry
Hostess gifts: to placate the netherworld gods such as Marduk
ANCIENT MESOPOTAMIA
Objects from the Royal Tombs of Ur
ANCIENT MESOPOTAMIA
Afterlife: The Rough Guide

How to have a good time: your happiness after
death depends on the quality and quantity of
offerings made by your survivors


offerings must be made continually to ensure success
in the afterlife
How to have an awful time: if your survivors
don’t make offerings, or if your death is violent
or premature, your restless ghost wanders the
earth attacking people
Four Major World
Religions
Judaism
Christianity
Islam
Hinduism
Judaism
JUDAISM
Origin of Death

“God saw all that he had made, and it was very good”
Gen 1.31




The first humans, Adam and Eve, disobey God Gen 3
Death is introduced to the world as a consequence of
human disobedience: “for dust you are and to dust you
will return” Gen 3.19
Being bene Adam (sons of Adam) makes all future
people subject to the penalty of death
Thus death is an inevitable and feared event
JUDAISM
What happens when we die?



Death occurs when rwh, divine life-giving force that
distinguishes living from dead, leaves body
Body returns to dust and rwh returns to air or to God
In ancient Judaism, no guarantee of life after death
for individual Jew
JUDAISM
What happens after we die?

Sheol as metaphor for death:



ghostly, subterranean land of dead
inferior copy of life on earth
not necessarily hell (i.e., a place of torment), but
certainly place to avoid for as long as possible as it
entails permanent separation from God – even for
righteous person
JUDAISM
Sheol

“The days of my life are few enough: turn your eyes
away, leave me a little joy, before I go to the place of
no return, the land of murk and deep shadow, where
dimness and disorder hold sway, and light itself is like
the dead of night.” Job 10.18-22
JUDAISM
What happens after we die?

The possibility of an afterlife



Hope for individual’s life after death was widespread
by Rabbinic period as seen in Dead Sea Scrolls
In medieval times, Maimonides stated that one who
doesn’t believe in resurrection of dead isn’t a true Jew
“O my God, the soul which you gave me is pure: you
created it, you formed it, you breathed it into me, you
preserve it within me; and you will take it from me.
But you will restore it to me in the hereafter.” Authorized
Daily Prayer Book p. 5
JUDAISM
Care of the Dying
Presence at time of death/departure of soul
 Recitation of at least last part of Shema (Deut
6.4-5) at moment of death
 Shut eyes and mouth of deceased
 Place sheet over his/her face
 Position his/her feet facing doorway
 Do not leave deceased alone before burial

JUDAISM
Preparing the Body





Immediate preparation for burial to preserve human
sanctity
Close family members should not be present during
preparations
All deceased persons, rich or poor, wrapped in same
simple, white shroud reflecting belief that all people
considered equal
Shrouded body wrapped in prayer shawl with one
fringe cut off to symbolize mourning and loss
Cremation and embalming are forbidden
JUDAISM
Funeral Rites




Funeral lamentations in presence of deceased
“Rending the garments”: mark of separation with tear
made over heart region to symbolize broken heart
Recitation of Psalm 23 and other Psalms pertaining
to person’s life
Eulogy praises deceased and expresses grief on
behalf of mourners and rest of community
JUDAISM
Burial Rites

Burial on day of death: “His body
shall not remain all night … you
shall bury him on that day.”
Deut 21:23

Simple wooden casket since wood
decomposes at roughly same rate
as body


In Israel no caskets are used– body is
interred only in prayer shawl
In ancient times, after body’s
decomposition, bones were preserved
in ossuary
JUDAISM
Burial Rites
JUDAISM
Burial Rites


Kaddish (Aramaic word meaning "holy" or
"sacred”): special prayer for deceased recited as dirt
shoveled onto grave
Funeral guests must wash their hands after contact
with dead (need for purification)
JUDAISM
Mourning Rituals

Shivah (“seven”): week-long period of
mourning, placing aside everyday routine to
focus attention on grief






Sitting low as a symbol of "being brought low" in grief
No "luxurious" bathing or cutting hair (no vanity)
Wearing cloth slippers or sandals instead of shoes
Covering mirrors (again, no vanity)
No business transactions
Holding memorial services in home both morning and evening
JUDAISM
Mourning Rituals


Sheloshim (“thirty”): second, less intense,
period of mourning which includes Shivah plus
23 days; mourners return to "normal" routine
and activities
Kaddish: repeated at Yahrzeit (first anniversary
of death) and at other memorial services
(Yizkor) four times yearly
Christianity
CHRISTIANITY
Origin of Death

Shared with Judaism
(and later, Islam):

“Original sin” of first
humans brought
penalty of death not
only to Adam and Eve
but to all people
CHRISTIANITY
The most important death…

Crucifixion of Jesus


common means of
execution of criminals in
Roman Empire
“…the soldiers took charge
of Jesus. Carrying his own
cross, he went out to the
place of the Skull (which
in Aramaic is called
Golgotha). Here they
crucified him….” John 19.16-18
CHRISTIANITY
…because it ends all Death

Resurrection of Jesus:


“…our Savior Jesus Christ
...destroyed death and has
brought life and
immortality…” 2 Tim 1.10
“Death is swallowed up in
victory: O Death, where is
thy sting? O grave, where
is thy victory?” Hosea 13.14/1
Cor 15.54-55
CHRISTIANITY
Doctrine of Resurrection


Formulated based on eyewitness accounts of Jesus’
death and resurrection as
well as on his teachings
“For as by man came
death, by a man has come
also the resurrection of the
dead. For as in Adam all
die, so also in Christ shall
all be made alive.” I Cor
15.21-22
CHRISTIANITY
What happens after we die?

Destination determined by individual’s acceptance or
rejection of salvific death and resurrection of Jesus

Heaven





Eternal life for believer in “perfected” body
Life in continual presence of God
Absence of death, pain, grief, war, conflict
Metaphors of “streets of gold”, etc.
Hell



Separation from God
Limited period (annihilationism) or eternal punishment
Metaphors of “lakes of fire and brimstone”
CHRISTIANITY
How is death observed?

During life: through Sacraments


Baptism: “we were buried with him [Christ] through
baptism into death in order that, just as Christ was
raised from the dead through the glory of the Father,
we too may live a new life [on earth and in the
afterlife].” Rom 6.4
Eucharist: “whenever you eat this bread and drink this
cup, you proclaim the Lord’s death until he comes.” 1
Cor 11.26
CHRISTIANITY
Moment of Death

Last rites: “into thy hands, Merciful Savior, we
commend the soul of thy servant, now departed
from the body … receive him into the arms of
thy mercy…”The Book of Common Prayer
CHRISTIANITY
Preparing the Body


Deceased’s body treated with great respect
Care taken to prepare body for burial reflects
Christian belief in eternal life and bodily
resurrection
CHRISTIANITY
Funeral Rites

In Roman Catholic Church (and others), friends and
family gather evening before main funeral liturgy to
pray and keep watch with deceased’s family


Prayers offered for deceased as well as those who have been
bereaved
Funeral mass: time to commend deceased to God's
mercy and to take strength from Eucharist which
celebrates the death and resurrection of Christ
CHRISTIANITY
Funeral Rites
CHRISTIANITY
Burial Rites


Traditionally, burial of body in grave or tomb
(as Jesus was buried in tomb)
Cremation not forbidden in most branches of
Christianity
Islam
ISLAM
Origin and Purpose of Death

Origin of death: as in Judaism and Christianity


Will of God:


original sin of Adam and Eve, and its punishment: “In the earth
you will live, and in it you will die …” Quran 7.24
“It is not possible for a soul to die except with the permission of
God at a term set down on record.” Quran 3.139
Time of trial:

Life is time of probation and decision: while alive, individuals
are free to direct their lives along straight path back to God
(sirat ulMustaqim) or to reject God Quran 1.5
ISLAM
What happens when we die?

Body and spirit: separated, then reunited



Bashar: “flesh” or body
Ruh: God’s “breath” or soul which animates bashar;
persists after death but exists apart from body until
reunion on Day of Resurrection
Nafs: “spiritual vitality” linking body and soul;
escapes at time of death (and also leaves body at night
in sleep and returns in morning) Quran 6.60f
ISLAM
What happens after we die?





Angel of death gathers those due to die Quran 32.10/9-11
Body is buried and decays
Soul escapes and may either be raised into interim
body or remain in suspended state
Body and soul reunited on Day of Resurrection (yaum
ulQiyama): “…we will raise him up on the day of
resurrection…”Quran 20.125
Appearance before God on Day of Judgment (yaum
udDin)
ISLAM
Judgment and Afterlife

Day of Judgment: “on the Day of Resurrection we will
bring out a written record: each man will see it spread
open” Quran 17.14



No one can “redeem” or “atone” for another’s misdeeds
Garden of Reward: for those who turn to God during
life (eternal pleasure)
Fire of Jahannam: for those who reject God during life
(eternal burning with fire)
ISLAM
Comforting the Dying

When Muslim nears death, those around him remind
him of God's mercy and forgiveness by:




Reciting verses from Quran
Giving physical comfort
Encouraging him to pray, particularly declaration of faith:
"I bear witness that there is no god but Allah"
Those with deceased encouraged to remain calm, pray
for departed, and begin preparations for burial
ISLAM
Preparing the Body



Close deceased’s eyes
Wash body with clean and scented water, in manner similar to
ablutions for prayer
Wrap body in sheets of clean, white cloth (kafan)
ISLAM
Preparing the Body
Burial within 8 hours if possible
 No embalming or other disturbance of body
 Autopsy may be performed, if necessary, but
done with utmost respect for dead

ISLAM
Funeral Rites
 Funeral
prayers commonly held
outdoors, in courtyard or public square,
not inside mosque
ISLAM
Funeral Rites



Community gathers and
imam stands in front of
deceased, facing away
from worshippers
Prayers over dead (four
takbirs: proclamations of
God’s greatness)
Recitation of whole
Quran if possible
ISLAM
Funeral Rites

Mourning should not be excessive: this disturbs
dead and shows lack of acceptance of God’s
will/purpose regarding death:

When Muhammad's own son died, he said: "The
eyes shed tears and the heart is grieved, but we
will not say anything except which pleases our
Lord."
ISLAM
Funeral Rites


Only men of community accompany body to grave
site
Cemetery set aside for Muslims is preferred
ISLAM
Burial Rites


Body is laid in grave (without coffin if permitted by
local law) on right side, facing Mecca
Tombstones, elaborate markers, flowers and other
mementos are discouraged
ISLAM
Mourning Period

Family and friends observe 3-day mourning period


Increased devotion, receiving visitors and condolences, and
avoiding decorative clothing and jewelry
Widows observe extended mourning period (iddah) of
4 months and 10 days Qur'an 2:234

Widows must not remarry, move from their homes, or wear
decorative clothing or jewelry
Hinduism
HINDUISM
Traversing a Continuum
“Hinduism is the map of how to live
appropriately … in order to move
towards (and perhaps attain) the goal”
J Bowker, The Meanings of Death. Cambridge: CUP, p. 131
HINDUISM
Eternal Soul

Soul does not die with body:

“Those who are truly wise do not mourn for the dead
any more than they do for the living. … Just as
embodied selves pass through childhood, youth and
old age in their bodies, so too there is a passing [at
death] to another body.” Bhagavad Gita 2.12
HINDUISM
Goal: Free the Self

Brahman/Nirvana: freed self has attained state of
wisdom regarding soul’s eternality
 Freedom achieved by renouncing all desires:
absence of preoccupation with bodily self
Gita 2.71f


State of power experienced both in life and after
death
State of happiness and peace from being eternally
with Krishna
HINDUISM
Cycle of Death and Rebirth

Self is unchanged yet reborn repeatedly until it finds it
way to liberation with guidance from Gita and other
scriptures



Samsara: cycle of rebirth which continues until
brahman/nirvana is reached
Karma: actions and consequences; bad karma can only be
overcome by achieving moksha (release that comes when one
realizes that one cannot influence karma)
Kashi: dying in right city provides shortcut to moksha…
HINDUISM
Insignificance of Death



During samsara, death occurs many times and
is thus of little importance
One death is merely a stage, a milestone, in a
long process
Continuing self has already passed on when
“person” dies (or is cremated)

if one is good, soul leaves through brahmarandhra
(small opening in crown of head) but if one is evil, it
leaves through anus
HINDUISM
Afterlife
Preta: intermediate condition of soul
immediately after death
 Judgment and afterlife:

Early literature: domain of Yama, ruler of ancestors
(place where families reunited and pain and sorrow of
this life removed)
 Later and post-Vedic literature: vivid descriptions of
hell-like places of torture and punishment (narakas),
where the punishment fits the crime

HINDUISM
Moment of Death

Meditation on God at time of death:




soul can influence its next form
aided by namakirtana, or chanting god’s name
until one ceases to be aware of anything else
Preferable to die at home
Candle is lit by deceased’s head
HINDUISM
Preparing the Body



Body is placed at house
entrance with head
facing south
Body is bathed,
anointed with
sandalwood and
wrapped in cloth
Elaborate funeral
processions
HINDUISM
Funeral Rites

Cremation is ideal method for dealing with dead
(although holy men, Untouchables and infants are
buried):




Releases soul of: “the eye to the sun, the breath (atman) to
the wind, the body to the plants” Rig Veda 10.16.3
Controls pollution created by death
Allows family to be brought back into society because
death causes separation
Preferably takes place on day of death
HINDUISM
Funeral Rites
HINDUISM
Funeral Rites

Closest relative of
deceased (usually eldest
son) lights funeral pyre
by accepting flaming
kusha twigs from Doms
(Untouchable Hindu
caste responsible for
tending funeral pyres)
HINDUISM
Funeral Rites



Body is an offering to
Agni, god of fire
After cremation, ashes and
bone fragments are
collected and immersed in
holy river, e.g., Ganges
After funeral, mourners
undergo purifying bath
HINDUISM
Mourning Rituals



Immediate family remains
in state of intense pollution
for set number of days
Then close family members
meet for ceremonial meal
and often give gifts to the
poor or to charities
Rice balls (pinda) offered to
dead person’s spirit during
memorial services
HINDUISM
Mourning Rituals

Contribute to deceased’s merit and pacify his soul so
it will not linger ghost-like in world but pass through
realm of Yama, god of death:


Ekoddista: ritual to render benign a deceased individual’s
preta
Sraddha: 16-stage ritual taking up to a year and including
not only one deceased individual but also up to 4
generations of ancestors
Modern Medicine
How Doctors took the Place of Priests
at the Deathbed
The Medicalization of Death


In ancient times, doctor’s presence at deathbed was
rare: this was priest’s role
When involved at all, doctor’s role was merely to
predict time of death –so priest could do his job
C Seale. Constructing Death. Cambridge: CUP, 1998, pp. 76-78
The Medicalization of Death

After the Enlightenment, dying under medical care became a
“status symbol” as medicine was finally empowered to “do
battle” with death




Dissection enabled improved understanding of pathophysiology
Diseases were described and categorized
New vision of “natural death” was available: death at end of long life
due to clinically identifiable illness
Death could even be prevented (or at least delayed) by understanding
disease
C Seale. Constructing Death. Cambridge: CUP, 1998, pp. 76-78.
Religion, Medicine and Death
“… modern rationality, of which medicine
is an example, is itself a religious
orientation, providing an imagined
community, rites of inclusion and
membership, and guidance for a
meaningful death.”
Seale. Constructing Death. Cambridge: CUP, 1998, pp. 75-76.
Cradle to Grave
Death as Biological Imperative




Cells are preprogrammed to apoptose after
certain number of divisions
DNA errors accumulate over time with
continued environmental exposures
Cumulative effects of cell death impair organ
functions needed to sustain life
Teleologically, death may be adaptive at
population level: people don’t compete with
their offspring for scarce resources
Searle. Constructing Death. Cambridge: CUP, 1998, pp. 35-36
DEFINITIONS OF DEATH
Cardiopulmonary Death




Previously easily diagnosed by irreversible cessation of
respiration and circulation which necessarily led to death of
all organs
After advent of ventilators, death no longer equated with
absence of circulation and respiration since machines could
sustain these functions
Use of this definition would jeopardize organ harvesting for
transplants due to organ deterioration during period
immediately after cessation of respiration and circulation
Currently accepted in USA as one of two valid definitions
A Scholthauer and B Liang, “Definitions and implications of death.” Hematology/oncology Clinics of North America 16:6 (2002)
DEFINITIONS OF DEATH
Whole-Brain Death



1968: Harvard Medical School committee defines death as
irreversible coma: “a state of unreceptivity and
unresponsivity, with no movement, breathing, or reflexes,
accompanied by a flat EEG”
1970: Kansas legally recognizes “the absence of spontaneous
brain function” as equivalent to cardiopulmonary death
1980: Uniform Determination of Death Act declares that “an
individual who has sustained either (1) irreversible cessation
of circulatory and respiratory functions, or (2) irreversible
cessation of all functions of the entire brain, including the
brain stem, is dead”
DEFINITIONS OF DEATH
Whole-Brain Death
By this definition, healthy organs can be
harvested as artificial circulation and
respiration are maintained
 USA, Germany, Japan, and France all accept
this definition of death

DEFINITIONS OF DEATH
Higher-Brain Death



Applicable to PVS patients: those without cortical
function responsible for emotion, cognition and
awareness but who maintain at least partial brain stem
function
Courts have been reluctant to adopt this definition
because absence of higher, cortical brain activity is
harder to prove with certainty, at least in short term
However, some courts have allowed “life”-sustaining
treatment of PVS patients to be discontinued (e.g.,
Quinlan, Cruzan, Schiavo)
Modern Medical Death Rites






Life insurance: manages consequences of one’s death
Wills: disposition of one’s possessions after death
Death certificates: enshrine in law “cause of death”
Autopsies: identify cause of death if not obvious
Inquests: identify cause of death if suspected to be
“unnatural”
Burial (+/- embalming) OR cremation and interment of
ashes: confines deceased to known “resting place” also
serving as memorial
Death in Society:
Doctors and Patients
Nationality
Ethnicity
Class
DOCTORS
Differences in End-of-Life Care
 Death
in ICU preceded by decision to
limit care:




Belgium: 65%
Canada: 70%
USA: 75%
Israel: 91%
J-L Vincent, “Cultural differences in end-of-life care.” Critical Care Medicine 29:2 (2001)
DOCTORS
Differences in End-of-Life Care

Decisions to withhold versus withdraw care—survey
of western European physicians
 93% sometimes withheld treatment
 77% sometimes withdrew treatment
 Physicians with strong religious beliefs (and those
from countries with deeper religious roots such as
Greece, Italy and Portugal) less likely to withdraw
life support
J-L Vincent, “Cultural differences in end-of-life care.” Critical Care Medicine 29:2 (2001)
DOCTORS
Differences in End-of-Life Care

Withdrawal of nutrition considered acceptable in
PVS patients in:
 USA: 89%
 Britain: 65%
 Belgium: 56%
 Japan: 17%
J-L Vincent, “Cultural differences in end-of-life care.” Critical Care Medicine 29:2 (2001)
PATIENTS
Differences in End-of-Life Decisions

Ethnicity:
 Patients in cultures that are more individualistic,
secular, pragmatic, scientific tend to prefer full
open awareness—as opposed to cultures which
are familial, sacred, traditional, emotional




In favor of closed awareness: Mexican, Japanese
In favor of full open awareness: Anglos
Most interested in carrying out wishes of dying: Japanese
Most wills and life insurance: Anglos
C Seale. Constructing Death. Cambridge: CUP, 1998, pp. 179-181
PATIENTS
Differences in End-of-Life Decisions

Ethnicity:

In USA, whites significantly more likely than blacks—
 to discuss treatment preferences before death
 to complete living wills
 to designate Durable Medical Power of Attorney
 to limit care in certain situations and withhold treatment
before death
S Hopp and S Duffy, “Racial variations in end-of-life care.” Journal of the American Geriatrics Society
48:6 (2000)
PATIENTS
Differences in End-of-Life Decisions

Class:

Persons of higher socioeconomic class are
2.7 times more likely to desire full open
awareness of terminal diagnosis
C Seale. Constructing Death. Cambridge: CUP, 1998, p. 179
The Individual
“My Death”
Images of Death
“I Will Die”
What is required to
grasp this notion:
“I will die”
 How can I use what I
know about life to
construct an
understanding of its
negation, death?




Self-awareness
Logical thought
Conceptions of:






Probability
Necessity
Causation
Time
Finality
Separation
R Kastenbaum. The Psychology of
Death. New York: Springer, 2000,
pp. 30-35
Death and Psychological Development

Developmental Stage 1: Up to age 5
–
–
–
Death is not final
Death is diminution of aliveness
Death involves separation
Nagy, in R Kastenbaum. The Psychology of Death. New York: Springer, 2000, 51-53
Death and Psychological Development

Developmental Stage 2: Ages 5-9
–
–
–
Death is final
Death is not inevitable – if one is clever and
lucky
Death personification – death as separate
person
Nagy, in R Kastenbaum. The Psychology of Death. New York: Springer, 2000, 51-53
Death and Psychological Development

Developmental Stage 3: Over age 10
–
–
–
Death is final
Death is inevitable
Death is universal
Nagy, in R Kastenbaum. The Psychology of Death. New York: Springer, 2000, 51-53
Stages of Dying
1.
2.
3.
4.
5.
Denial
Anger
Bargaining
Depression
Acceptance
E Kubler-Ross, in R Kastenbaum. The Psychology of
Death. New York: Springer, 2000, 216-217
Getting the Timing Right

“The material end of the
body is only roughly
congruent with the end of
the social self. In extreme
old age, or in disease, when
mind and personality
disintegrate, social death
may precede biological
death. Ghosts, memories
and ancestor worship are
examples of the opposite: a
social presence outlasting
the body.”


Euthanasia: social death
is pre-empted by
actively hastening
biological death
Hospice: social death is
pushed back as far as
possible until biological
death occurs
C Seale. Constructing Death. Cambridge: CUP,
1998, pp. 34, 184
BIBLIOGRAPHY














Canine, John D. The Psychosocial Aspects of Death and Dying. Stamford: Appleton & Lange, 1996.
Chirban, John T., ed. Coping with Death and Dying: An Interdisciplinary Approch. Lanham: University Press of America,
1985.
Haas, Volkert. “Death and the Afterlife in Hittite Thought.” Civilizations of the Ancient Near East, ed. Sasson, Jack M.
Volume IV. New York: Scribner, 1995, pp. 2021-2030.
Hopp, Faith P. “Racial Variations in End-of-Life Care.” Journal of the American Geriatrics Society, 48:6 (June 2000).
Humphreys, S.C. and Helen King, eds. Mortality and Immortality: The anthropology and archaeology of death. London:
Academic Press, 1981.
Kastenbaum, Robert. The Psychology of Death. New York: Springer, 2000.
Kleinfeld, N. R. “In Death Watch for Stranger, Becoming a Friend to the End.” New York Times, January 25, 2004, pp.
A1,A20-21.
Lesko, Leonard H. “Death and the Afterlife in Ancient Egyptian Thought.” Civilizations of the Ancient Near East, ed.
Sasson, Jack M. Volume III. New York: Scriber, 1995, pp. 1763-1774.
Rosenberg, Jay F. Thinking Clearly About Death. Englewood Cliffs: Prentice-Hall, 1983.
Schlotzhauer, Anna V. and Bryan A. Liang. “Definitions and Implications of Death.” Hematology/oncology Clinics of North
America, 16:6 (Dec 2002).
Scurlock, Jo Ann. “Death and the Afterlife in Ancient Mesopotamian Thought.” Civilizations of the Ancient Near East, ed.
Sasson, Jack M. Volume III. New York: Scriber, 1995, pp. 1883-1893.
Seale, Clive. Constructing Death: The Sociology of Dying and Bereavement. Cambridge: CUP, 1998.
Vincent, Jean-Louis. “Cultural Differences in End-of-Life Care.” Critical Care Medicine, 29:2 (Feb 2001).
Xella, Paolo, “Death and the Afterlife in Canaanite and Hebrew Thought.” Civilizations of the Ancient Near East, ed.
Sasson, Jack M. Volume IV. New York: Scriber, 1995, pp. 2059-2070.