Within the last few years, interest has become manifested in many aspects of dying. At the same time, more attention is being paid to the aged and tp their concerns. Due to the aging process and concomitant diseases, the aged are considered to be nearer death than are people in other age groups. It is important for nurses who work with the aged to have a clear understanding of the concepts of both dying and aging and especially of the altitudes of the aged toward dying.
As a background to this focus, three theories regarding death arid dying will be discussed. Otte of the theories that is currently popular is that developed by Dr. Elisabeth Kubier -Ross.1 Her research has pointed out five stages that a dying person commonly experiences prior to the actual death.
The first stage usually encountered by a dying person, according to Dr. Kubler-Ross, is that, of denial. That is, the person refuses to believe thereality that he is dying. Most people usé at least partial denial and may revert to it again later after other stages have also been encountered. Although denial is usually temporary, it serves to cushion the person from the shocking knowledge of impending death. It allows the person to calm himself and to mobilize Other defenses. The previous lifestyles of aged persons determine to a great extent how they will express denial. The expression is also influenced by the way the person is told of his impending death, the time available to him in which to acknowledge his death gradually, and the way he has handled stress in earlier stages of his life.
Anger is the second stage identified by Kubler-Ross. This stage is especially hard on the people around the person as this anger is likely to be expressed in all directions and projected onto everyone as well a? the environment. The people who are the targets of that anger are quite likely not the causes. Everyone and everything serve as reminders to the person of all that he is about to lose. He may feel that he is already being ignored and forgotten as well as having all his activities so prematurely terminated. Envy and resentment are predominant feelings, especially for those persons who have held strict control over their actions and decisions iri earlier stages of life.
The third stage is termed bargaining. This is less obvious than other stages as the vow may be made silently to God or may be expressed to only one person such as a chaplain. After being angry, the person is seen as trying a new approach, namely that of good behavior. However, the promises made are seldom kept or if the deadline is reached, the person then asks for an additional extension of life. Common purposes of bargains are to be able to complete one last task, to live until an important event, or to see a distant loved one one more time. Quiet guilt of ten underlies this stage.
Next is the stage of depression or preparatory grief The person is grieving over his approaching final separation from this world. He is naturally sad and feels a great loss- of everything and everybody he loves. He also seems to be withdrawing from his loved ones at; this time, but that withdrawal is necessary to enable him to reach a final acceptance of his impending death.
Acceptance is the final stage and is the prelude toa' peaceful death. Then the person feels tired and weak but has a somewhat quiet expectation when contenv plating the coming end. He may feel lonely and alienated at the same time his interests diminish. He needs thé presence of someone even though he cannot respond to that person.
The second theorist to be discussed is: Dr. Cecily Saunders whose work at Saint Christopher· s Hospice has received much attention.2"4 There, she advocates individual regimes for each patient to include pain relief and a positive approach. She believes the cancer patients at St. Christopher's can be enabled to race their deaths with courage and dignity and eantnaintain an alert and peaceful frame of mind. She also advocates support to the patients' relatives and friends. The staff is rather large there as their members spend much time with the patients They feel that "being present" is their most important function. Relatives, including chil* dren, are always welcome. They sometimes help the; nurse and stay overnight. These measures have been instituted to ease the separation of dying and possible abandonment by the living.
Physical care includes emphasis on food and analgesia, Visitors are welcome to bring patients' favorite foods. Feeding is all done by hand without the use of apparatus at any time. Alcohol consumption is permitted as desired, and families and staff can also share drinks with patients. Alcohol is seen as a social, psychological, and physical support. In regard to pain, the staff emphasizes anticipating and preventing it rather than having to alleviate it. Frequent, low dosages of heroin is the treatment of choice.
In communicating with a patient about his impending death, the staff tries to listen to him and handle the issue as he desires. Some admit they are dying, while others continue to deny it; but in each case, the staff tries to respond as the patient indicates. The staff members purposely cultivate abilities to listen and to follow the patients' approaches to their dying.
Glaser and Strauss5 have studied the awareness of dying of terminal patients and the interaction that occurs between these patients and the hospital staff. They also use the term "dying trajectory" as a person's socially defined course of dying. Such trajectories are perceived rather than actual courses of dying since social dimensions of dying depend on whether or not the perceiver sees the person as dying and on the perceiver's expectations of the proceedings of the dying. Such perceptions by a doctor, nurse, or family member become the basis for the perceiver's relationship to the patient. Such a trajectory may be speedy or slow, expected or unexpected, appropriate or inappropriate.
An awareness context is composed of the information each interacting person has regarding the patient's defined status, along with his recognition of others' awareness of his own definition. Glaser and Strauss have described four types of awareness context that are: closed awareness, suspected awareness, mutual pretense awareness, and open awareness.
In the closed awareness context, the patient is unaware of his terminal condition although medical personnel know of it. Conditions contributing to this context include these: few people are experienced at recognizing the signs of impending death; few American physicians tell patients that death is probable or inevitable; families try to guard the secret; the physical arrangements of hospitals and the commitment of personnel guard the facts; and the patient has no allies to help him discover the truth.
The suspicion awareness context occurs when the patient suspects he is dying and tries to verify those suspicions while others are trying to negate those same suspicions. It is also possible that the staff does not recognize those suspicions for some time or that they may be wondering whether or not the patient has become suspicious.
Mutual pretense is another context in which both the patient and staff realize that he is dying, but both pretend otherwise. They all act as though he were going to live. Either side can initiate or terminate the pretense.
The final context is that of open awareness when both the patient and staff acknowledge that he is dying. There may still be ambiguities, however, if the patient does not know how close death is, how badly he may deteriorate, or if the patient and staff disagree on how a person "should" die.
As the positions of Kubler-Ross, Saunders, and Glaser and Strauss have been viewed, the discussion will now turn to the attitudes of the aged toward death. The relationships of religion and culture upon those attitudes will be described, along with other factors seen to influence one's reaction to the news of a fatal illness.
The aged, according to Butler,6 tend to fear death less than do young people, but they do especially fear dying alone. They are usually more concerned about the deaths of relatives and friends than of themselves. They may even welcome death as a release and as a resolution of life experiences. Kubler-Ross7 sees the situation somewhat differently in that the aged may not accept death but only welcome it because life has lost its worth. She sees the lives of many elderly as lacking love and personal interaction and believes they face death only with resignation.
Research by Kalish and Reynolds8 at the Ethel Percy Andrus Gerontological Institute produced the following conclusions. They found that the elderly have encountered death more than have younger people in that most of the elderly sampled had lost a spouse through death, had known persons who had recently died, had attended more funerals, and had visited more graves. Also, the elderly were more likely to have made out a will and arranged for funeral ceremonies and cemetery purchase. The older person was more likely to indicate acceptance of death, along with more preoccupation with the topic. He is more likely to worry about what happens to the body after death, while younger people more frequently admit being afraid of death and dying. The elderly are less concerned about dependents than are the young and are less worried about the termination of life experiences. On the other hand, they are not anxious to die and do not feel that death should be precipitated.
The overall American culture has a distinct tendency to promote both the denying and defying of death as a defense against being hurt by death. This statement is opposed by Parsons and Lidz9 who see that Americans respond to death in a fashion called "instrumental activism" that is seen to be consistent with their general orientation to life.
A paradox is seen in the way American newspapers confront death by publishing many items relating to death. This would make it seem that Americans can face and accept çleath; but death is a rather taboo topic in conversations, both public and private. Likewise, they do not discuss the process of dying, and it has already been seen that a dying person is often not informed of that fact. This lack of information is especially pronounced when the patient and staff come from divergent class or ethnic membership.5
Within the United States, there are many cultural differences and as many ways of viewing death. The blacks are one group whose attitudes toward death and dying have been studied.8 It was found that this group expects to and would like to live longest (as compared to Anglos, Japanese- Americans, and Mexican-Americans) in spite of their overall poor health and high mortality rate. They do have a very low suicide rate as opposed to more contact with victims of homicide, accidents, and wartime deaths. Most blacks state that they never dream about their own death and seldom even think about it. This is in marked contrast to the fact that many of their spirituals and novels deal with the theme of death. For support during cases of death and dying, older blacks tend to rely less upon relatives and more on religious symbols and persons for comfort. With increasing devoutness and age, blacks rely even less on relatives.
In the Japanese-American culture,8 there was the strongest indication that the spouse should be at one's deathbed to provide water, a damp cloth, etc, and to hear and carry out the last wishes. In spite of such devotion, people of this culture are quite controlled in their expression of grief. Very few Japanese- Americans reported thinking of their own deaths even weekly, and one third claimed to never think about their own death. About one half of the Japanese-American sample believed that someone should be told he is dying. At the same time, 80% thought a dying person senses that his death is imminent.
The Japanese-Americans were significantly more likely to know of someone whose suicide had been reported under some other category of death. Each person would emphasize that suicide did not run in his family arid that he would never consider killing himself. The conclusion drawn was that the JapaneseAmericans are very concerned with social reputation.
The Japanese- Americans attached little importance to the fact that death would put an end to all their plans and projects. Very few said that given six months to live, they would try to complete projects and tie up loose ends in the interim. Very few of the JapaneseAmericans stated ihey had ever felt close to dying themselves, although several reported psychic experiences in regard to death. In contrast to the blacks, the least religiously devout Japanese- Americans seemed to be more accepting of death.
Only the Japanese-Americans (as opposed to blacks, Mexican-Americans, and Anglos) thought of the death of a man as more tragic than that of a woman. They were also the least likely to touch the body of a dead spouse at the funeral. Their attitudes toward dating and remarriage by the survivor were extremely conservative.
The Mexican -American aspect of Kalish and Reynolds'8 study yielded these conclusions. If they had six months to live, they would be most concerned about others and would want to be with loved ones. They would be free to express their loss and to cry over the death of a loved one and would be concerned if they could not cry. The Mexican -Americans are more likely to touch the body of the deceased and still believe in wearing black clothing for a year or more.
The Mexican-Americans were very protective of the feelings of others in that they do not feel a dying person should be told, and that they personally could not tell someone that he was dying.
In marked contrast to the dominant United States culture, many people do not take their dying to a hospital. For example in an Arabian village, one dies at home with one's children, grandchildren, and possessions, such as animals. Also, Malayans are very suspicious of hospitals. They seldom let an ill relative go to a hospital and quickly take him home when he seems to be dying.5
Trelease10 has described the dying Alaskan Indians. During his years as a parish priest in Alaska, he observed that the "dying people exhibited a willfulness about their dying, their participation in its planning, and the time of its occurrence that showed a remarkable power of personal choice."
The Jewish view of death was delineated by Rabbi Heller.11 The rituals of the Jewish culture, as set down in the Jewish law "provide for death with dignity and meaning - allowing the dying person to set his house in order, bless his family, pass on any messages to them he feels important, and make his peace with God."
It has been found that older people turn more and more to the sacred and to the traditional to find comfort in times of bereavement and to aid their quest for immortality. Older persons both adhere more closely to those traditions and also see themselves as more devout than younger people. They consider One's religious background as the most important influence on his outlook toward death and are more likely to believe in life after death.8
Alexander and Adlerstein12 have studied the relationship of death and religion and reached these conclusions. The religious people sampled were found to think more frequently about their own deaths, especially when ill. They also thought their religious convictions made death seem less fearful. Most of the religious subjects became aware of the phenomenon of death before age six, while few of the nonrehgious subjects had done so. The religious group was particularly concerned in regard to the existence or not of an afterlife, while the nonreligious subjects worried about their dying without having accomplished anything important.
"Reactions to death are closely related to a resolution of life's experiences and problems as well as a sense of one's contributions to others. Profound religious and philosophical convictions facilitate acceptance. Religion has been the traditional solace by promising another world."6
Christianity views death as the end of one's earthly pilgrimage and as the fulfillment of one's existence, 13 as opposed to the relation of death to Hinduism and Buddhism. The latter two generally agree that life cannot be meaningful unless the fact of death is fully accepted. One who tries to ignore death robs his life of purpose, while one who faces death courageously will come to see it as a companion and finally a friend. They see birth as a rebirth that occurs soon after death.14
The news that one is soon to die can have varying effects on the person and usually interferes with the processes of anticipation and hope. Such stress, along with the physical process of the illness, often leads to regression and a resultant change in the person's selfimage. So the person begins again to live day-to-day instead of planning several months ahead. The question of how much to tell a person and in what manner can be answered by an assessment. Factors to be assessed include: the person's ego strength; presence or absence of denial mechanisms; the nature and meaning of the illness; role of the family; and factors pertinent to hospitalization and to the physician-patient relationship.15
After the initial depression of a person after receiving the fatal news, his reaction may take several forms. Denial is prevalent and sets in immediately, especially when the disclosure has been rather sharp or abrupt. Acceptance of the news may be shown by active or passive preparation for death. This may take the form of settling social and financial affairs or may involve philosophical and/or religious preparations. Suicide is one form of preparation in that it eliminates the last days of the dying process. Passive preparation may take the form of nonchalance, calm resignation, or a nonverbal kind of acceptance. Some persons try to fight their fatal illnesses, engaging in such behavior as intensive living, going to marginal doctors or to quacks, and taking part in experiments. They may engage in strenuous activities inappropriate to their conditions.5
Another topic of concern to the aged and their nurses is that of euthanasia, which can be categorized as voluntary or involuntary and direct or indirect. Direct, voluntary euthanasia approximates a form of suicide. Voluntary, indirect means that a person arranges in advance for discretionary action to end his life when he becomes too dysfunctional to participate. In cases of involuntary euthanasia, the patient has not consented for his death. Involuntary direct euthanasia is commonly called a "mercy killing" or consists of positive action. Negative action or inactioa heips release the patient from suffering in indirect, involuntary euthanasia.16
Generally, active steps to hasten death are not approved, but factors to artificially prolong life may be avoided. The decision to commit inaction rests finally with the physician who should consult the patient, if possible and the family. Such a decision may be even more difficult in regard to elderly patients who may vacillate between lucidity and disorientation.
Arguments in favor of euthanasia accent the social values of preventing cruelty and liberty. Cruelty may be encountered either in the suffering of the patient or of his relatives. Liberty relates to the thought that a person should have the ultimate decision about what to do with his life.
Opposition to euthanasia relies on both secular and religious arguments in saying that any form of killing is wrong. Some Christians believe that pain may lead a sinner to repentance. Some secular objections to the legalization of euthanasia include the claim that physicians already perform whatever euthanasia is necessary with a danger of abuse due to the difficulty of obtaining consent. There is a risk of an incorrect diagnosis along with the possibility of new medical discoveries. Use of modern pain medication is also seen to decrease the possible need for euthanasia.16
Attitudes of the aged toward death are strongly influenced by their cultural and religious backgrounds. Nurses who are aware of this influence and have some knowledge of the various religious beliefs and cultural factors prevalent in the area where they practice are in a better position to give effective care to their elderly clients who may be facing death.
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- 11. Heller ZI: The Jewish view of death: Guidelines for dying, in Kubler-Ross E (ed): Death The Final Stage of Growth. Engiewood Cliffs, New Jersey, 1975.
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- 13; Kutscher AH, Kutscher LG (eds): Religion and Bereavement. New York. Meilen Press Inc. 1972.
- 14. Long JB: The Death That Ends Death in Hinduism and Buddhism, in Kubler-Ross E (ed): Death the Final Stage of Growth. Engiewood Cliffs, New Jersey, 1975.
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- 16. Beauchamp, JM: Euthanasia and the Nurse Practitioner. Nurs Forum 14:56-73, 1975.