CONTEXTUALIZING DEATH

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CONTEXTUALIZING DEATH

• Sonya Merrill, MD, PhD
• Presbyterian Hospital of Dallas
• September 7, 2005

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OUTLINE

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

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Ancient Cultures

• Egypt
• Mesopotamia

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Ancient Egypt
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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

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ANCIENT EGYPTThe 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 persons image or statue and
  thought to be a protecting genius after death
• Suyt a persons shadow

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ANCIENT EGYPTThe 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)

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ANCIENT EGYPTCanopic Jars
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ANCIENT EGYPTThe 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
  
  

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ANCIENT EGYPTThe Body and Its Burial

• The Opening of the Mouth ceremony eyes, ears,
  nostrils and mouth touched to symbolize opening
  and persons revival
• Tombs contained biographical information to
  preserve occupants name and reputation varied
  according to importance of deceased
• VIP burial arrangements
• Old Kingdomwooden coffin inside stone
  sarcophagus
• Middle Kingdomhuman-shaped wooden coffin with
  mask over mummys head inside stone sarcophagus
• New Kingdomelaborately painted anthropoid nested
  coffins, e.g., Tutankhamuns 3 nested coffins

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ANCIENT EGYPTThe Body and Its Burial
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ANCIENT EGYPTAfterlife 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

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ANCIENT EGYPTAfterlife 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

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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

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ANCIENT EGYPTAfterlife The Rough Guide

• Traveling companions
• Models of servants included for purpose of
  eternally producing necessary supplies

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Ancient Mesopotamia
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ANCIENT MESOPOTAMIAGeneral 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

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ANCIENT MESOPOTAMIAGeneral Principles

• Euphemism speaking of death summons it, so
  instead
• to cross the Khubur, to go up to heaven, to
  go to ones fate, to be invited by ones gods,
  to come to land on ones mountain, to go on
  the road of ones 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

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ANCIENT MESOPOTAMIAThe 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

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ANCIENT MESOPOTAMIAThe 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

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ANCIENT MESOPOTAMIAFuneral 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

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ANCIENT MESOPOTAMIAAfterlife 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 gatekeepers permission

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ANCIENT MESOPOTAMIAAfterlife 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
  deceaseds earthly behavior)

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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

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ANCIENT MESOPOTAMIA Objects from the Royal Tombs
of Ur
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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
  dont make offerings, or if your death is violent
  or premature, your restless ghost wanders the
  earth attacking people

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Four Major World Religions

• Judaism
• Christianity
• Islam
• Hinduism

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Judaism
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JUDAISMOrigin 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

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JUDAISMWhat 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

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JUDAISMWhat 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

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JUDAISMSheol

• 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

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JUDAISMWhat happens after we die?

• The possibility of an afterlife
• Hope for individuals life after death was
  widespread by Rabbinic period as seen in Dead Sea
  Scrolls
• In medieval times, Maimonides stated that one who
  doesnt believe in resurrection of dead isnt 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

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JUDAISMCare 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

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JUDAISMPreparing 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

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JUDAISMFuneral 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 persons life
• Eulogy praises deceased and expresses grief on
  behalf of mourners and rest of community

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JUDAISMBurial Rites

• Burial on day of death His body shall not
  remain all night you shall bury him on that
  day.
• Deut 2123
• 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 bodys decomposition,
  bones were preserved in ossuary

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JUDAISMBurial Rites
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JUDAISMBurial 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)

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JUDAISMMourning 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

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JUDAISMMourning 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

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Christianity
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CHRISTIANITYOrigin 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

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CHRISTIANITYThe 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

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CHRISTIANITYbecause 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

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CHRISTIANITYDoctrine of Resurrection

• Formulated based on eye-witness 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

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CHRISTIANITYWhat happens after we die?

• Destination determined by individuals 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

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CHRISTIANITYHow 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 Lords death until he
  comes. 1 Cor 11.26

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CHRISTIANITYMoment 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
  mercyThe Book of Common Prayer

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CHRISTIANITYPreparing the Body

• Deceaseds body treated with great respect
• Care taken to prepare body for burial reflects
  Christian belief in eternal life and bodily
  resurrection

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CHRISTIANITYFuneral Rites

• In Roman Catholic Church (and others), friends
  and family gather evening before main funeral
  liturgy to pray and keep watch with deceaseds
  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

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CHRISTIANITYFuneral Rites
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CHRISTIANITYBurial Rites

• Traditionally, burial of body in grave or tomb
  (as Jesus was buried in tomb)
• Cremation not forbidden in most branches of
  Christianity

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Islam
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ISLAMOrigin and Purpose of Death

• Origin of death as in Judaism and Christianity
• original sin of Adam and Eve, and its punishment
  In the earth you will live, and in it you will
  die Quran 7.24
• Will of God
• 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

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ISLAMWhat happens when we die?

• Body and spirit separated, then reunited
• Bashar flesh or body
• Ruh Gods 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

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ISLAMWhat 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 resurrectionQuran 20.125
• Appearance before God on Day of Judgment (yaum
  udDin)

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ISLAMJudgment 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 anothers
  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)

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ISLAMComforting 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

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ISLAMPreparing the Body

• Close deceaseds eyes
• Wash body with clean and scented water, in manner
  similar to ablutions for prayer
• Wrap body in sheets of clean, white cloth (kafan)

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ISLAMPreparing 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

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ISLAMFuneral Rites

• Funeral prayers commonly held outdoors, in
  courtyard or public square, not inside mosque

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ISLAMFuneral Rites

• Community gathers and imam stands in front of
  deceased, facing away from worshippers
• Prayers over dead (four takbirs proclamations of
  Gods greatness)
• Recitation of whole Quran if possible

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ISLAMFuneral Rites

• Mourning should not be excessive this disturbs
  dead and shows lack of acceptance of Gods
  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."

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ISLAMFuneral Rites

• Only men of community accompany body to grave
  site
• Cemetery set aside for Muslims is preferred

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ISLAMBurial 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

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ISLAMMourning 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 2234
• Widows must not remarry, move from their homes,
  or wear decorative clothing or jewelry

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Hinduism
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HINDUISMTraversing 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

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HINDUISMEternal 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

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HINDUISMGoal Free the Self

• Brahman/Nirvana freed self has attained state of
  wisdom regarding souls 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

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HINDUISMCycle 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

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HINDUISMInsignificance 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

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HINDUISMAfterlife

• 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

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HINDUISMMoment of Death

• Meditation on God at time of death
• soul can influence its next form
• aided by namakirtana, or chanting gods name
  until one ceases to be aware of anything else
• Preferable to die at home
• Candle is lit by deceaseds head

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HINDUISMPreparing 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

79
HINDUISMFuneral 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

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HINDUISMFuneral Rites
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HINDUISMFuneral 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)

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HINDUISMFuneral 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

83
HINDUISMMourning 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 persons
  spirit during memorial services

84
HINDUISMMourning Rituals

• Contribute to deceaseds 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
  individuals 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

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Modern Medicine

• How Doctors took the Place of Priests
• at the Deathbed

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The Medicalization of Death

• In ancient times, doctors presence at deathbed
  was rare this was priests role
• When involved at all, doctors role was merely to
  predict time of death so priest could do his job
• C Seale. Constructing Death. Cambridge CUP,
  1998, pp. 76-78

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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.

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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.

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Cradle to Grave
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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 dont compete with their
  offspring for scarce resources
• Searle. Constructing Death. Cambridge
  CUP, 1998, pp. 35-36

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DEFINITIONS OF DEATHCardiopulmonary 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 166 (2002)

92
DEFINITIONS OF DEATHWhole-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

93
DEFINITIONS OF DEATHWhole-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

94
DEFINITIONS OF DEATHHigher-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)

95
Modern Medical Death Rites

• Life insurance manages consequences of ones
  death
• Wills disposition of ones 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

96
Death in Society Doctors and Patients

• Nationality
• Ethnicity
• Class

97
DOCTORSDifferences 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 292 (2001)

98
DOCTORSDifferences in End-of-Life Care

• Decisions to withhold versus withdraw caresurvey
  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 292 (2001)

99
DOCTORSDifferences 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 292 (2001)

100
PATIENTSDifferences in End-of-Life Decisions

• Ethnicity
• Patients in cultures that are more
  individualistic, secular, pragmatic, scientific
  tend to prefer full open awarenessas 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

101
PATIENTSDifferences 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 486 (2000)

102
PATIENTSDifferences 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

103
The Individual

• My Death

104
Images of Death
105
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

106
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

107
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

108
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

109
Stages of Dying

• Denial
• Anger
• Bargaining
• Depression
• Acceptance
• E Kubler-Ross, in R Kastenbaum. The Psychology of
  Death. New York Springer, 2000, 216-217

110
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

111
BIBLIOGRAPHY

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