CONTEXTUALIZING DEATH Sonya Merrill MD Ph D Presbyterian

CONTEXTUALIZING DEATH Sonya Merrill, MD, Ph. D Presbyterian Hospital of Dallas September 7, 2005

OUTLINE Death in the Context of: Two ancient cultures n Four major world religions n Modern medicine n Society n The individual n

Ancient Cultures Egypt Mesopotamia

Ancient Egypt

ANCIENT EGYPT General Principles Preoccupation with life and desire to “continue living” after death n Afterlife resembles an improved earthly life n Continuing bodily existence: n n n mummification attempts to recover bodies fear of being eaten by animals “Ideal” life span: 100 years

ANCIENT EGYPT The Soul n n 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 n n 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 n n 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 n Step 2: Removal of other organs n n n 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 n n n 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: n n n 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 n How to get there: by boat, sailing on a day-night journey with the Sun God n navigate using basic spells from funerary texts left near the body

ANCIENT EGYPT Afterlife: The Rough Guide n Where to go when you arrive: n Field of Offerings: a land on the western horizon where the deceased work in fields and orchards to harvest offerings for Osiris n Paradise: where the deceased reaps the fruits of his own labor and enjoys a blissful existence

ANCIENT EGYPT Afterlife: The Rough Guide n What n n n 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 n Traveling companions: n Models of servants included for purpose of eternally producing necessary supplies

Ancient Mesopotamia

ANCIENT MESOPOTAMIA General Principles n Death is inevitable: “when the gods created men, they set aside death for mankind and kept eternal life in their own hands” n 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 n Euphemism: speaking of “death” summons it, so instead: n n “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 n n n 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 n n 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 n Preparation: ceremonial washing, tying mouth shut, perfuming, dressing in clean clothes n Public viewing: before the funeral n Burial: in the ground in a coffin, sarcophagus or tomb n n Elites were buried in vaults below their houses or palaces while others were buried in public cemeteries Last rites: burnt offering n When a king died, his throne, table, weapon and scepter were burned

ANCIENT MESOPOTAMIA Funeral Customs n n n 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 n Where: underground n n 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 n Your hosts: meet the royal couple, Nergal and Ereshkigal, and their courtiers who: n n n 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 n How to pack: take as many personal items as you can afford n n n 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 n How to have a good time: your happiness after death depends on the quality and quantity of offerings made by your survivors n n 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 n “God saw all that he had made, and it was very good” Gen 1. 31 n n 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? n n n 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? n Sheol as metaphor for death: n n n 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 n “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? n The possibility of an afterlife n n n 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 n Recitation of at least last part of Shema (Deut 6. 4 -5) at moment of death n Shut eyes and mouth of deceased n Place sheet over his/her face n Position his/her feet facing doorway n Do not leave deceased alone before burial n

JUDAISM Preparing the Body n n n 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 n n 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 n Burial on day of death: “His body shall not remain all night … you shall bury him on that day. ” Deut 21: 23 n Simple wooden casket since wood decomposes at roughly same rate as body n n 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 n n 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 n Shivah (“seven”): week-long period of mourning, placing aside everyday routine to focus attention on grief n n n 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 n Kaddish: repeated at Yahrzeit (first anniversary of death) and at other memorial services (Yizkor) four times yearly n

Christianity

CHRISTIANITY Origin of Death n Shared with Judaism (and later, Islam): n “Original sin” of first humans brought penalty of death not only to Adam and Eve but to all people

CHRISTIANITY The most important death… n Crucifixion of Jesus n n 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 n Resurrection of Jesus: n n “…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 n n 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 be made alive. ” I Cor 15. 21 -22

CHRISTIANITY What happens after we die? n Destination determined by individual’s acceptance or rejection of salvific death and resurrection of Jesus n Heaven n n 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 n n n Separation from God Limited period (annihilationism) or eternal punishment Metaphors of “lakes of fire and brimstone”

CHRISTIANITY How is death observed? n During life: through Sacraments n n 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 n 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 n Care taken to prepare body for burial reflects Christian belief in eternal life and bodily resurrection n

CHRISTIANITY Funeral Rites n In Roman Catholic Church (and others), friends and family gather evening before main funeral liturgy to pray and keep watch with deceased’s family n n 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) n Cremation not forbidden in most branches of Christianity n

Islam

ISLAM Origin and Purpose of Death n Origin of death: as in Judaism and Christianity n n Will of God: n n 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: n Life is time of probation and decision: while alive, individuals are free to direct their lives along straight path back to God (sirat ul. Mustaqim) or to reject God Quran 1. 5

ISLAM What happens when we die? n Body and spirit: separated, then reunited n n n 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. 60 f

ISLAM What happens after we die? n n n 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 ul. Qiyama): “…we will raise him up on the day of resurrection…”Quran 20. 125 Appearance before God on Day of Judgment (yaum ud. Din)

ISLAM Judgment and Afterlife n 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 n n n 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 n When Muslim nears death, those around him remind him of God's mercy and forgiveness by: n n 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 n n n 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 n No embalming or other disturbance of body n Autopsy may be performed, if necessary, but done with utmost respect for dead n

ISLAM Funeral Rites n Funeral prayers commonly held outdoors, in courtyard or public square, not inside mosque

ISLAM Funeral Rites n n n 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 n Mourning should not be excessive: this disturbs dead and shows lack of acceptance of God’s will/purpose regarding death: n 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 n n Only men of community accompany body to grave site Cemetery set aside for Muslims is preferred

ISLAM Burial Rites n n 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 n Family and friends observe 3 -day mourning period n n 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 n 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 n Soul does not die with body: n “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 n Brahman/Nirvana: freed self has attained state of wisdom regarding soul’s eternality n Freedom achieved by renouncing all desires: absence of preoccupation with bodily self Gita 2. 71 f n n 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 n Self is unchanged yet reborn repeatedly until it finds it way to liberation with guidance from Gita and other scriptures n n n 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 n One death is merely a stage, a milestone, in a long process n Continuing self has already passed on when “person” dies (or is cremated) n n 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 n Judgment and afterlife: n Early literature: domain of Yama, ruler of ancestors (place where families reunited and pain and sorrow of this life removed) n Later and post-Vedic literature: vivid descriptions of hell-like places of torture and punishment (narakas), where the punishment fits the crime n

HINDUISM Moment of Death n Meditation on God at time of death: n n 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 n Candle is lit by deceased’s head n

HINDUISM Preparing the Body n n n 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 n Cremation is ideal method for dealing with dead (although holy men, Untouchables and infants are buried): n n 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 n 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 n n n 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 n n n 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 n 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: n n 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 n n 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 n After the Enlightenment, dying under medical care became a “status symbol” as medicine was finally empowered to “do battle” with death n n 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 n DNA errors accumulate over time with continued environmental exposures n Cumulative effects of cell death impair organ functions needed to sustain life n Teleologically, death may be adaptive at population level: people don’t compete with their offspring for scarce resources n Searle. Constructing Death. Cambridge: CUP, 1998, pp. 35 -36

DEFINITIONS OF DEATH Cardiopulmonary Death n n 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 n n n 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 n USA, Germany, Japan, and France all accept this definition of death n

DEFINITIONS OF DEATH Higher-Brain Death n n n 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 n n n 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 n Death in ICU preceded by decision to limit care: n n 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 n Decisions to withhold versus withdraw care—survey of western European physicians n 93% sometimes withheld treatment n 77% sometimes withdrew treatment n 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 n Withdrawal of nutrition considered acceptable in PVS patients in: n USA: 89% n Britain: 65% n Belgium: 56% n 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 n Ethnicity: n 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 n n 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 n Ethnicity: n In USA, whites significantly more likely than blacks— n to discuss treatment preferences before death n to complete living wills n to designate Durable Medical Power of Attorney n 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 n Class: n 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” n How can I use what I know about life to construct an understanding of its negation, death? n n Self-awareness Logical thought Conceptions of: n n n Probability Necessity Causation Time Finality Separation R Kastenbaum. The Psychology of Death. New York: Springer, 2000, pp. 30 -35

Death and Psychological Development n 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 n 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 n 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 n “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. ” n n 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 n n n n 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. A 1, A 20 -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.