"1 get so depressed when I think about death. I wouldn't want to talk about death with old people; that would just make them more depressed too, wouldn't it?"
"Old people have lived a long time and are probably ready for death. After all, what's left to live for?"
These two common stereotypes about the aged and their attitudes about death are supported widely by young and middle-aged aduits, including many health professionals, although neither statement describes all attitudes toward death of any group of persons at any age. Believing these and similar misconceptions may affect relationships profoundly between aged persons and their families, friends, and providers of their health care.
First, what do we know about death attitudes along the life span? How do differences in time perspectives affect attitudes toward death? How do the attitudes of care givers toward aging and death affect their relationships with aged persons? Finally, how can we learn from the old themselves?
While there are differences in the conclusions reached by Maria Nagy and Adah Maurer a clear picture emerges of development over time, with individual factors being at least as important as age.1'2 Says Nagy, "the theory the child makes of death faithfully reflects at each stage a general picture of its world," a relationship that can be expected to continue throughout life. With each child's thoughts and attitudes about death depending on individual factors as well as general age level, individual experience can be expected to play a much larger role in death attitudes as the child grows through the years of adulthood into old age.
As we consider old persons' attitudes toward death, first a caution: Munnichs3 and Wass4 speak against viewing aged persons as a homogeneous group, while Herman Feifel,5 a long-time student of old persons' attitudes toward death, states that "the unique feature of old age development is the inevitability of death, bringing with it the tasks of integrating one's past life and the acceptance of one's own death." Surely this effect will be differently experienced at 60 than at 90. In studying the many meanings of death, Feifel worked with a group of World War 1 veterans.6 Many saw death as "the end of everything," others as "new life," and a few saw it bringing "relief and peace." Regarding what happens after death, some believed that "when you're dead, you're dead," many more expected a judgment or spiritual experience, while a very few expected a "long sleep." When asked when in life they had most and least feared death, almost half feared death when over 70, some when in their 40 's and others when in their 20's. The least fear was reported to have been in childhood by one group, while another reported the least fear when over 70.4
The influence of religion on death attitudes was studied by Swenson, who found that highly religious persons tended to look forward to death, while those with little religious activity tended to fear death.7 Swenson comments that "investigators postulating a relatively common fear of death in the persons they study probably have resorted to subjective or indirect inferences," pointing to how our own views of death affect the way we interpret the attitudes of others.
Kalish and Reynolds carried out an extensive study of death attitudes among adults of various ethnic groups and age categories.8 They concluded from these extended interviews that "the role of age was particularly important. The elderly not only had encountered significantly more death.... but they also thought more often about their own death and dying. Nonetheless, older persons were least likely to indicate fear of their own death. By and large, the young adults were at the opposite end of the continuum while the middle-aged were intermediate. These results support other findings that older persons are more accepting of death in general and their own death in particular than younger persons."
One final aspect of the comparison of death attitudes of young and old persons to consider is the influence of changing time perspectives. Robert Kastenbaum has written frequently about the meanings of time. In 1966 he contrasted the time meanings of adolescents and late life adults in contemporary America.9 Adolescents, he observed, tended to project themselves only into the near future and back into the very recent past, tending to "limit their scanning of their life-span to approximately 1235." He believed that this was related to a strong focus on the development of a sense of s e If -identify, with aging and death seen as a "massive threat, the termination of a sequence that is still in process of development.'0
A good, old age, in terms of time meanings, may be one in which the individual has integrated past/ present/future perspectives, with an ability to use the past, value the present, and the flexibility to project one's self into the future, a balance of engrossment in the moment and perspective on one's past and future. Conversely, Kastenbaum discusses two approaches to passing time which may lead to unhappiness in late life. In one, the person may continue to practice delayed gratification inflexibly into late life, not allowing one's sense of personal future to be modified over time with a realistic adaptation to "time running out." This may result in a bitter sense of having been cheated out of the future gratification for which one has sacrificed so much present pleasure for so long.
On the other hand, some persons concentrate only on the present, and never see themselves as old-in-thefuture, continuing to cling to past achievements, roles and relationships without developing new goals and coping abilities. Old age then may come as an unanticipated crisis of identity.
Finally, in Ronald Blythe's A View in Winter, the author quotes extensively the many English old people he interviewed, some of them speaking about their changing time perspectives:
"When you're 92 and you say, 'when I was 74,' it is almost like saying 'when I was young'!"
"Old age is full of death and full of life. It is a tolerable achievement and it is a disaster. It transcends desire and it taunts it. It is long enough and it is far from long enough."
"I don't think that I ever thought about being old, when 1 was being young! And I wouldn't want it ... life ... all over again. Once is enough."10
Effects of Professional Attitudes:
Blythe observes that "the growing bureaucracy, amateur and professional, voluntary and state, for dealing with geriatrics, makes some old folk feel that they no longer quite belong to the human race any more."10
Innés sees as one source of this distanced attitude as "a common factor underlying lack of communication between doctor and patient (and by extension, between other professionals and their clients), (that of) the failure of the doctor to put himself in the position of the person asking advice. The 'distance 'be t wee n the patient and the doctor may have become too great, with the patient's body becoming more heterogeneous with more variable wants and needs, and the doctor becoming too specialized or too technically minded in approach." If this is true, these diverging paths can be expected to become even more divergent over time and thus with older patients/ clients.
McTavish describes stereotyped views of old people which very likely interfere with this "putting in the other's (the old person's) place":
"Stereotyped views of the elderly uncovered in various studies include views that old people are generally ill, tired, not sexually interested, mentally slower, forgetful and less able to learn new things, grouchy, withdrawn, feeling sorry for themselves, less likely to participate in activities (except, perhaps, religion), isolated, in the least happy or fortunate time of life, unproductive and defensive in various combinations with varying emphases."1"
This stereotyped view of old age as a homogeneous condition is in sharp contrast to the view of psychiatrist Kathy Gribbin:
"Any broad generalization is necessarily lacking when applied to a specific individual, and this is definitely so in the case of the elderly. Older people have had a lifetime to accumulate many different and varied experiences. They have exercised their abilities and capabilities in a multitude of ways. In addition, older people are physiologically very different from one another. It is very possible that older people are the most heterogeneous age group as concerns variation in functioning."'3
It can readily be seen that professional distancing and depersonalizing of aged persons probably has complex personal, cultural and social roots, and is not -likely to be dissipated easily. Feifel suggests that "death's meaning for the individual can serve as an important organizing principie in determining how one conducts himself in life."6 However, he also writes that "the agony of selfhood is not endurable for most of us in pondering death without resources, be they transcendental, inspirational or existential. We pay expensively for the taboo we affix to the subject of death. Closer psychological familiarity with death is called for in our developmental upbringing and culture.'*
One avenue to this closer familiarity with death is to learn from those who have considered it longest and are growing closest to it. Salter and Salter support this in suggesting that death anxiety is related to fears of one's own aging but not to factual knowledge or images of elderly persons, and that this anxiety would be dealt with either by avoidance/ denial or by constructive attitude change and behavioral adaptation. Their study of a group of students gives moderate support to the latter strategy in that "people who fear death (tend to) help reduce its terrors by supporting the elderly."14
Wass and associates find that "it is clear that old persons have strong convictions and opinions concerning death and dying, and are willing to express them when given the opportunity."1 Not everyone who wants to learn from the old will feel comfortable approaching the subject of death directly, but will often be invited to share the old person's views about death in the process of sharing reminiscences. Robert Butler, in writing of reminiscence/ life review, describes life review as:
"characterized by the progressive return to consciousness of past experiences and particularly the resurgence of unresolved conflicts which can be looked at again and reintegrated ... (a successful review) can give new significance and meaning to one's life and prepare one for death, by mitigating fear and anxiety."15
Implications for Nursing Practice
Of what consequence is all of this for the practicing nurse? In the early stages of systematic development of standards for nursing practice, the American Journal of Nursing proposed nine standards for geriatric nursing practice. Two of these standards in particular speak directly to this concern:
* The nurse demonstrates an appreciation of the heritage, values, and wisdom of older persons.
* The nurse seeks to resolve her conflicting attitudes regarding aging, death and dependency so that she can assist older persons, and their relatives, to maintain life with dignity and comfort until death ensues.16
In commenting on these standards, the authors suggest that appreciation for the heritage, values, and wisdom of the older persons leads to respect for the older person as an individual and enrichment of the nurse's life. They note further that in seeking to resolve one's own conflicting attitudes, the nurse's functioning and personal satisfaction achieved in nursing are increased and one's capacity to express empathy and compassion are enlarged.
Much has been written in nursing textbooks and journals about death and the care of dying persons. These standards emphasize that underlying such care must be the nurse's own ongoing clarification and resolution of attitudes and feelings toward death. The studies we have been discussing suggest that this ongoing process will be enhanced by listening carefully and empathically to those who have experienced the deaths of others and considered their own death over the longest time - the aged themselves.
Opportunities for careful listening may occur spontaneously within ongoing nurse/ aged patient relationships. Often the aged make seemingly casual remarks about death to test the nurse's openness to empathie listening on the subject. If these remarks are accepted with encouragement, the nurse may be invited to share the patient's reflections. In the process, both the aged patient and the nurse may achieve a measure of that new significance and meaning to life and the mitigation of anxiety about death of which Robert Butler spoke.15
In addition to such spontaneous opportunities, some nurses set out in a more deliberate fashion to encourage reminiscence and life review. This may take the form of group reminiscence experiences scheduled at regular intervals. Individual reminiscence opportunities may also be initiated by the nurse who is alert to the need and readiness of the person to participate.
Finally, the tape recording of oral histories may be initiated by an interested nurse. This requires time and quiet surroundings, often scarce commodities in the context of nurse/ aged patient encounters. However, seizing the opportunity when it does present itself can pay rich dividends for both reminiscer and listener/ recorder. The following are fragments from two tape-recorded histories shared with the author.
The first was recorded at the request of a 96-year-old man who said that he thought he'd lived a pretty interesting life and would like to share it. He proceeded with gentle humor to describe his life as a selfdescribed "rolling stone" from his birth in Norway, his journey to America at the age of 19, and his lifetime of moving about the country as a laborer. Never married, he chose to settle in a residential facility at age 82, his first and highly prized permanent home, where he died a few months after this recording was made. Toward the end of his account, he proceeded to record his gratitude to specific persons and to the people as a whole in his home, and then concluded with these words:
"Ya, I can tell you that I have been traveling up and down on life's highway for a number of years, longer than most of *em and . . . the road has been kind of rough in places, smooth again and then rough again, and it's been up one hill and down another for a number of years. But then I come to a big hill, where it was difficult to climb, but 1 made the top of the hill by zigzagging across and back. And maybe when I think back, I think I zigged some places where I shouldVe zagged. Now then 1 made the hill, and now I'm on the way down the other side of the hill where the territory is unknown to me. And I believe that I take God along as a guide (and) hell guide me safely down the hill."
The second fragment is taken from the oral history of an 81 -year-old American-born woman, widowed a few years before the time of taping, still vigorously alive at 87 at this writing. The recording took place over some time, covering her childhood, her college and work experience, and her courtship, marriage and motherhood. At that time she was invited to record any thoughts she might have about old age, of which she said, "1 can't think of anything constructive to say about it. "Later, when she reconsidered she recorded a variety of realistically constructive thoughts, including accounts of her many experiences with the deaths of persons close to her. In this context she said:
"I think . . . such a sure feeling that death is good makes, in my aging process, well, I don't feel as if I'm pushing away death, and that death would be a welcome thing as a closing to a person's life . . . rather than too long an existence at any cost. I like that word 'jubilant,' and it seems to me that time will be a jubilant occasion, 'be swift my soul to answer him, be jubilant my feet,* and that thrills me."
We cannot expect that all of the aged will have attained this degree of integration and serenity, or that any other views are necessarily less desirable or adaptive. Indeed, through a lifetime of experiencing, each person fashions a unique and complex tapestry of values, beliefs and attitudes. The aged have been there - they are the teachers. Let us learn from them.
- 1. Nagy MH. The child's theories concerning death. Journal of Genetic Psychology 73 (1948), 3-27 .
- 2. Maurer A: Maturation of concepts of death. British journal of medical psychology 39 (1966), 35-41.
- 3. Munnichs JMA, in Discussion of a symposium on attitudes toward death in older persons. Journal of gerontology 16 (1961), 60-63.
- 4. Wass H et al. Similarities an dissimilarities in attitudes toward death in a population of older persons. Omega 9:4 (1978-1979), 337-354.
- 5. Feifel H: In discussion of a symposium on attitudes toward death in older persons. J Geronloi 1961; 16:60*63.
- 6. Fiefel H: Attitudes toward death: A psychological perspective, in Schneidman ES (ed): Death: Current Perspectives. Palo Alto, Mayfield Publishing Co, 1976, pp 423-429.
- 7. Swenson WM. Attitudes toward death in an aged population. Journal of Gerontology 16(1961), 49-52.
- 8. KalishRAandReynotdsDK.Theroleof age in death attitudes. Death education 1 (1977), 205-230.
- 9. Kastenbaum R. On the meaning of time in later life. Journal of genetic psychology 109:1 (September 1966), 9-24.
- 10. Blythe R: The View in Winter. New York, Hareourt Brace Jovanovieh, 1979.
- 11. Innés JM. Does the professional know what the client wants? Social science and medicine 11 (1977), 635-638.
- 12. McTavish DG. Perceptions of old people: a review of methodologies and findings. Gerontologist (Winter, 1971), 90-108.
- 13. Gribbin K: Cognitive processes in aging, in Burnside IM (ed): Nursing and the Aged, ed 2. New York, McGraw-Hill Book Co, 1981.
- 14. Salter CA and Salter C deL. Attitudes toward aging and behaviors toward the elderly among young people as a function of death anxiety. Gerontologist 16:3 (June 1976), 232-236.
- 15. Butler RN: The life review: An interpretation of reminiscence in the aged. Psychiatry 1963; 26(l):65-76.
- 16. Standards for geriatric nursing practice. Am J Nurs 1970; 70(9).
- Brantner J: You Haven't Lived Yet, film. Lutheran Social Services of Minnesota.
- Burnside IM: Nur sing and the Aged, ed 2. New York, McGraw-Hill, 1981, pp 98-113.
- Butter RN: Viewpoint: Attitudes toward death. Geriatrics 1964; 19:58A.
- Fulton R: In Symposium on death and attitudes toward death. Geriatrics 1972; 27(8):52-60.
- Kastenbaum R. and Aisenberg R. Death as a thought. In Schneid ma n ES (ed.). Death: current perspectives. Palo Alto: Mayfield Publishing Co., 1976, 369-422.