Dr. Butler is Professor Emerita, George Mason University, College of Health and Human Services, Fairfax, Virginia.
The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Frieda R. Butler, PhD, RN, FAAN, FGSA, 4316 Pennbrooke Court, West River, MD 20778-9787; e-mail: firstname.lastname@example.org.
There are virtues in dying, especially when the caregiver allows the older adult nearing the end of life to tell his or her life story. Nurses and other caregivers are well aware of the need to provide physical comfort and pain relief; however, the outcomes of providing emotional and psychological comfort to dying older adults have been given less attention. Certainly, the emotional impact of unresolved conflicts, as well as successes, accomplishments, perceived failures, and other memorable events during the life span can be tremendous for older adults approaching the end of life. Particularly important is the need to express feelings and thoughts regarding these issues. Inability to reconcile their lives and express successes and failures may result in mental and emotional suffering and preclude a peaceful end.
Providing expert compassionate care to patients and their families who are experiencing illnesses with a terminal prognosis is a topic that has been written about extensively. Despite the rapid growth of the hospice movement in the United States and the well-established benefits of palliative care at end of life, it is believed that many health care providers fail to relieve end-of-life suffering and to ease the transition from life to death. This article addresses a strategy that can provide a peaceful death, as well as enhance the emotional health of well, chronically ill, and terminally ill older adults.
During the past 10 years, the author has trained more than 100 graduate nursing and gerontology students to conduct individual life reviews as a course requirement with older adults in various stages of health, from those at high-level physical wellness to those nearing death. Ages of the older adults ranged from 65 to 93, and the individuals represented a diversity of cultures including African American, Caucasian, and Asian American. Approximately 75 interviews were conducted in the clients’ own homes and approximately 25 in assisted living facilities. Students were advised to audio record the interviews if they were able or to take careful notes if recorders were not accessible. These were voluntary interviews, and no payment was required on the part of the older adult. Length of interview sessions lasted from 1 to 1.5 hours.
It appeared that the older adult’s desire to talk and share stories and experiences was the primary determinant of the length of the interview, rather than age or morbidity. As part of the training, interviewers were taught to be receptive, nonjudgmental, and accepting. They learned to encourage the older adults to discuss their lives and, if able, to analyze the dynamics of their lives. The interviewers were told to stop the interview if certain areas of recall or memories became too upsetting for the client or at the client’s request. Most of the clients preferred to tell their entire life histories and began to integrate any past conflicts.
In addition to the life interviews conducted by students as a part of course requirements, Butler et al. (2009) conducted a study with a small sample (N = 6) of older adults to determine whether a life review at end of life facilitated a peaceful end to that life. Four students participated in this study, which included six audio recorded interviews of hospice patients in their own homes. The investigators wanted to know how dying older adults responded to a life review and whether it facilitated a more peaceful end of life. To recognize that one’s life has had purpose and meaning and to reconcile long-lasting issues through a life review may facilitate a peaceful death (Butler, 1963). Further, life review for older adults, regardless of state of health, has been shown to maximize emotional and psychological health and level of self-esteem (Haight, Michel, & Hendrix, 2000; Peck, 2001).
Life review can be defined simply as telling one’s life experiences from the earliest memory to the present, progressing through all stages of life. This is a guided interview involving individual sessions, with a purpose of reviving past experiences, including calling to consciousness any unresolved conflicts, as well as pleasurable experiences (Butler, 1963; Haight & Burnside, 1992; Woods, 2004). The Life Review Guide (Haight, 1988) is used as a guide only, and the interviewer may ask additional questions, omit questions, or reword questions depending on the tone and progression of the interview. A few sample questions are included in the Sidebar on this page.
What is the first thing you can remember in your life? Go back as far as you can.
What was life like for you as a child?
Did someone important to you go away?
Do you remember being in a very dangerous situation?
When you think about yourself and your life as a teenager, what is the first thing you can remember about that time?
Who were the important people for you?
Did you attend church and youth groups?
Do you remember feeling left alone, abandoned, not having enough love or care?
Family and Home
How did your parents get along?
What was the atmosphere like in your home?
Who were you closest to in your family?
Were you punished as a child? Who did the punishing? For what? Who was the “boss”?
What was life like for you as an adult?
What kind of person were you?
Was there someone you shared your life with? How did you meet?
What were some of the challenges you faced in your adult years?
What were the “defining” moments in your life?
What are your greatest achievements?
What was the unhappiest period of your life?
What was the happiest period of your life?
What were the most difficult things you had to deal with in your life?
Tell me about your experience living with a terminal illness or coming to terms with your own mortality.
Do you have any other words of wisdom you would like to pass on?
Adapted with permission from Haight (1988).
This recall differs from reminiscence, in that reminiscence is a spontaneous, random recall of one’s past, whereas life review is a structured, systematic, and evaluative process (Reker, 2003). Life review is a guided recall of events in various stages of one’s life, whereas a psychiatric interview is more encompassing and complex, and requires additional psychiatric training. The traditional psychiatric interview derives from the medical model and uses a variety of psychodynamics that are not used in the life review process.
Life review is perceived as being therapeutic and important to older adults. To acquire or maintain maximum emotional health, older adults should understand that their lives have had depth and meaning. Other reasons for a life review include dealing with unresolved guilt, unachieved aspirations, and perceived failures. Also, issues related to “unfinished business” and conflicts in life may be better understood and perhaps resolved. Such confrontation may help resolve guilt and facilitate reconciliation (Woods, 2004). Satisfaction may be gained in knowing there were achievements and excitements in other periods of life. Other outcomes include enhanced self-esteem, a sense of pride in one’s accomplishments, a perception of the meaningfulness of one’s life, and a feeling of having done one’s best (Woods, 2004). Life review studies in general have shown that a sense of well-being increases when older adults, regardless of state of health, relate their life stories when guided by a trained interviewer (Haight et al., 2000; Peck, 2001; Serrano, Latorre, Gatz, & Montanes, 2004; Silver, 2002).
Life Review Interviews
Stories elicited through these interviews, as well as from a recent study (Butler et al., 2009), were very thoughtful and insightful, with expressed benefits to the clients and the students. During the process, the clients expressed a great deal of insight into their past lives. For example, Ms. J. realized that while she was growing up, topics such as sex, drugs, and death were taboo. There was little or no display of affection in her family. She is now making a stronger effort to have more open discussion of these topics with her family, to display affection, and to be more engaged with the community.
Another client, Ms. D., was able to ventilate her frustration at not being able to engage in the physical activities she once enjoyed; however, in relating this, she displayed an optimism to enjoy what she could in her remaining days. Interestingly, she instructed the student about the importance of attitude and a sense of humor in one’s life.
Clients with a terminal diagnosis who were interviewed at end of life were able to recall their most memorable events at each stage of their lives. Most indicated positive outcomes of the life review, especially specific events, illnesses, and/or injuries in their childhood, and indicated that they were able to cope with difficult issues, such as illness and life instability. They were quite willing to tell their stories and to present their achievements and conflicts. Interestingly, they discovered and related their current views on their past lives without undue emphasis on their illness as a limitation. What they gained from hard work and difficulties in their childhood helped them establish strategies for looking at things in a different way. They seemed to accept their illnesses and voiced few conflicts in their life reviews. Family relationships (i.e., parents and siblings); exposure to loss, death, and grief; and participants’ relation with church, religion, faith, and spirituality were acknowledged as the source and the focus of conflicts that were verbalized in their life reviews (Butler et al., 2009). The participants were able to accept what they had from their education and fit that with their life opportunities.
The majority of older adults interviewed had to traverse many changes and difficulties in their lives and their work, which necessitated their moving and traveling to different places. These changes, and their adaptation to these changes and difficulties, seemed to make it easier for them to accept their life situations and cope with their inner conflicts. The majority of the participants considered some of the events and conflicts in their life review as learning experiences that motivated them toward more achievements in their lives. Several stated that they would use the interview transcript to compose their obituaries. The following verbatim quotes from the participants reflect this:
- “I been thinking about the questions you’ve been asking, the things you’ve been doing and I think it is a great idea. I think that not many people would be in this position to relate any of their backgrounds, unless a person like you came in. Now I intend to do it, you are just gonna make it a lot easier because you’ve recorded a lot of the facts and put ’em down for me and I can just weave a kind of an obituary, a little history of my life.”
- “It brought back some memories that we didn’t talk about and that I hadn’t thought about for awhile, which was good.”
- “It was a relief to get it all out. There was a relief that I said it and it didn’t do me any harm.”
Participants often voiced considerable satisfaction at having told their stories and perceived an added meaningfulness of their lives (Butler et al., 2009). Many believed their lives to be mundane until the life review reminded them of their productiveness and impact on others. Surprisingly, it was found that many older adults wanted to teach the students a life lesson before they concluded the interview. One 82-year-old former U.S. Air Force colonel offered these words of wisdom at the conclusion of his review: “Live every day to the fullest and get the most you can out of each and every day.”
Using life review as a strategy to provide emotional relief and bolster self-esteem can provide significant benefits to older adults. Telling their life stories through a guided process is an excellent way to help older adults understand their lives and resolve issues and conflicts. By uncovering accomplishments in life and resolving conflicts, they may experience feelings of emotional relief and a more peaceful approach to death. By guiding them to recognize how a lifetime of hard work, spirituality, faith, and family culture helped them develop successful coping skills, health care professionals may enhance patient outcomes by facilitating a remembrance of accomplishments, reconciling conflicts and disappointments, and promoting emotional relief and a more peaceful approach to death.
Nurses and other health care providers should include an assessment of psychosocial health as a significant component of end-of-life care. Psychiatric nurses already possess communication skills; however, a class on conducting a life review teaches them how to incorporate this model into their repertoire of skills in caring for older adults. Including a life review may allow reconciliation and assure peace of mind and tranquility when nearing death. Every client is worthy of a peaceful end-of-life experience, and a life review can provide a means to emotional relief for the client. A larger randomized controlled study of life review with terminally ill older adults should be conducted to determine whether comprehensive quality care at end of life should include a life review intervention to allow reconciliation, peace of mind, and tranquility when nearing death.
- Butler, F., Johnson, S., Falk, N., Powers, M.K., Babgi, A. & Falk, N. (2009). Life review at end of life: Measures of outcomes. Manuscript submitted for publication.
- Butler, R.N. (1963). The life review: An interpretation of reminiscence in the aged. Psychiatry, 26, 65–76.
- Haight, B.K. (1988). The therapeutic role of a structured life review process in homebound elderly subjects. Journal of Gerontology, 43, P40–P44.
- Haight, B.K. & Burnside, I. (1992). Reminiscence and life review: Conducting the processes. Journal of Gerontological Nursing, 18(2), 39–42.
- Haight, B.K., Michel, Y. & Hendrix, S. (2000). Extended effects of the life review in nursing home residents. International Journal of Aging and Human Development, 50, 151–168. doi:10.2190/QU66-E8UV-NYMR-Y99E [CrossRef]
- Peck, M.D. (2001). Looking back at life and its influence on subjective well-being. Journal of Gerontological Social Work, 35(2), 3–20. doi:10.1300/J083v35n02_02 [CrossRef]
- Reker, G.T. (2003, November). Restoring, maintaining, and enhancing meaning and purpose in life through autobiographical methods. In Exploring mature lives: Autobiographical steps toward wisdom. Preconference workshop conducted at the meeting of the Gerontological Society of America. , San Diego, CA. .
- Rose Kennedy quotes. (n.d.). Retrieved from the Brainy Quote website: http://www.brainyquote.com/quotes/authors/r/rose_kennedy.html
- Serrano, J.P., Latorre, J.M., Gatz, M. & Montanes, J. (2004). Life review therapy using autobiographical retrieval practice for older adults with depressive symptomatology. Psychology and Aging, 19, 270–277.
- Silver, M.H. (2002). Significance of life review in old age. Journal of Geriatric Psychiatry, 35, 11–23.
- Woods, B. (2004). Review: Reminiscence and life review are effective therapies for depression in the elderly. Evidence-Based Mental Health, 7(3), 81. doi:10.1136/ebmh.7.3.81 [CrossRef]