CONTEXTUALIZING DEATH

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CONTEXTUALIZING DEATH

• Sonya Merrill, MD, PhD
• Presbyterian Hospital of Dallas
• January 27, 2004

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OUTLINE

• DEATH IN THE CONTEXT OF
• Two Ancient Cultures
• Four Major World Religions
• Modern Medicine
• Society Nationality, Ethnicity and Class
• The Individual

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Ancient Cultures

• Egypt
• Mesopotamia

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ANCIENT EGYPT General Principles

• Preoccupation with life and desire to continue
  living after death
• Belief that Afterlife would resemble but improve
  upon earthly life
• Importance of continuing bodily existence (e.g.,
  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, usually
  represented as a bird flying away at the time of
  death
• Akh the spirit which also survives death and
  which can be good or evil, equipped with spells
  that would be useful after death
• Ka difficult to conceptualize but often
  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 the decay-prone viscera
  enabling preservation of the majority of the 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 EGYPTThe Body and Its Preservation

• Step 2 Removal of other organs
• Heart seat of intelligence so after removal
  was 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 the natron, a natural
  desiccant
• Step 4 Complete drainage of all bodily fluids
• Step 5 Careful wrapping of the body in hundreds
  of 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, reputation varied
  according to importance of deceased
• VIP burial arrangements
• Old Kingdom wooden coffin inside stone
  sarcophagus
• Middle Kingdom human-shaped wooden coffin with
  mask over mummys head inside stone sarcophagus
• New Kingdom elaborately painted anthropoid
  nested coffins, e.g., Tutankhamuns 3 nested
  coffins

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ANCIENT EGYPTAfterlife The Rough Guide

• How to get there
• Funerary texts provided deceased with all
  necessary information to navigate the afterlife
• By boat sailing on day-night journey with the
  Sun God
• attainable using basic spells which were left in
  guidebooks near the body
• Where to go when you arrive
• Field of Offerings land in the western horizon
  where deceased would work in lush fields and
  orchards to produce offerings for the god Osiris
• Paradise 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
• Premise deceased require basic provisions to
  survive in the afterlife
• Initially, basic provisions such as bread, beer,
  meat, wine, linens were placed in tomb
• Later, models of provisions were deposited to
  guarantee that supplies would last
• Who to bring with you
• Models of servants responsible for provisions
  were included so that they could continue to
  produce necessary supplies forever

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ANCIENT EGYPTConclusions

• Optimistic belief that all bodily and spiritual
  aspects of person survived in afterlife
• Great effort to ensure that deceased not only
  survived but thrived in afterlife
• Mummification
• Opening of the Mouth ceremony
• Elaborate burials with provisions
• Guide books to the afterlife
• Spells to ensure deceaseds safety

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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
• Use of euphemisms speaking of death summoned it,
  so to die was 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
• A gradual process rather than an instantaneous
  end of earthly existence
• The individual corpse
• The individual ancestor dependent on descendents
  offerings
• After several generations, collective ancestral
  spirits
• Finally, annihilation of individual and recycling
  into new soul

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ANCIENT MESOPOTAMIAThe Soul

• Etemmu ghost closely 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 could leave body when person was asleep
  closest to modern equivalent of soul
• Both etemmu and zaqiqu descended with the body to
  the netherworld at death if the body had been
  destroyed, then etemmu was also destroyed leaving
  only shadowy zaqiqu which was deemed harmless

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ANCIENT MESOPOTAMIAThe Body and Its Burial

• Preparation of body ceremonial washing, tying
  the mouth shut, perfuming, dressing in clean
  clothes
• Public viewing before the funeral
• Burial in the ground in a coffin, sarcophagus or
  tomb
• Elite buried in vaults below their house or
  palace while others buried in public cemeteries
• Last rite a burnt offering, which in the case of
  the king consisted of burning his throne, table,
  weapon and scepter

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ANCIENT MESOPOTAMIAFuneral Customs

• Mourning rituals could last up to 7 days
• Family and close friends were expected to
  participate in the case of the death of royalty,
  the entire population had to mourn
• Professional mourners sometimes employed
• Funeral laments expressed mourners grief and
  eulogized the deceased
• Physical displays of grief wearing plain
  clothes, tearing clothes, wearing sackcloth, not
  bathing or grooming, fasting

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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

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ANCIENT MESOPOTAMIAAfterlife The Rough Guide

• Where underground
• Climate a rather dark, damp and dreary place
• How to get there cross demon-infested lands,
  pass the Khubur River with the aid of its
  guardian god, gain entry through 7 gates to the
  city of the netherworld with its gatekeepers
  permission
• Your hosts the royal couple, Nergal and
  Ereshkigal, and their court they welcome the
  dead, instruct them as to the local rules, and
  show them to their lodgings in the netherworld
  (which did not appear to be based on the
  deceaseds earthly behavior)

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ANCIENT MESOPOTAMIA Afterlife The Rough Guide

• How to be happy there your happiness after death
  depended on the quality and quantity of offerings
  made to you by your relatives offerings had to
  be made continually to ensure continued success
  in the afterlife
• How to have an awful time without offerings, or
  if your death had been violent or premature,
  youd be restless and your ghost would wander the
  earth attacking people
• Multiple-entry visas the deceased generally
  received offerings from behind the gates of the
  netherworld but were allowed out (and back in)
  several times a year to visit relatives (e.g.,
  the month of Abu July/August)
• Recycling policies eventually old souls were
  recycled into new human beings

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ANCIENT MESOPOTAMIAConclusions

• Some sort of ghostly existence after death which
  was accessed only via burial and mourning rituals
  
• No bodily resurrection or judgment
• The ideal death surrounded by family and friends
  while lying on the special funerary bed with a
  chair at ones left which served as the seat for
  the soul after its release from the body

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Four Major World Religions

• Judaism
• Christianity
• Islam
• Hinduism

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JUDAISMThe Origin of Death

• God saw all that he had made, and it was very
  good Gen 1.31
• The first humans disobey God Gen 3
• Death 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, the divine life-giving
  force, leaves the body rwh distinguishes the
  living from the dead

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JUDAISMWhat happens after we die?

• At death, the body returns to dust, and the
  breath which God breathed into it initially (rwh)
  returns to the air, or to God nothing can
  survive
• God makes his covenant (promises) with the Jews
  regarding their future on earth (e.g., the
  continuity of the nation and of ones
  descendents), not with regard to an individuals
  survival after death
• Thus death is acceptable only at the end of a
  long life when one has descendants who can
  preserve ones memory

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JUDAISMWhat happens after we die?

• Sheol as a metaphor for death
• a ghostly, subterranean land of the dead
• an inferior copy of life on earth
• not necessarily hell (i.e., a place of torment),
  but certainly a place to avoid for as long as
  possible chiefly because it entails permanent
  separation from God even for the righteous

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Sheol

• 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
• If God has been the Jews creator (in the past)
  and guardian (in the present), why not his
  sustainer (in the future)?
• During the Babylonian exile, there was an
  emphasis on the future restoration of Israel to
  peace and prosperity by the Messiah
• And if those Jews alive at this future time could
  be restored, why couldnt the faithful dead also
  experience a restoration to life (return of blood
  and breath)?
• Hope of an individuals life after death became
  widespread by the Rabbinic period Maimonides
  said that anyone who doesnt believe in the
  resurrection of the dead is not a true Jew

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JUDAISMWhat happens after we die?

• 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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JUDAISMWhat happens after we die?

• Transmigration
• According to the Kabbalah, souls can go from one
  body to another (gilgul, or transmigration)
  those deserving punishment or those who are
  extremely righteous

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JUDAISMHow is death observed?

• Be present at the time of death/departure of the
  soul
• Recite at least the last part of the Shema at the
  moment of death
• Accompany the body to the grave
• Funeral lamentations in the presence of the
  corpse
• Burial of the corpse (and in ancient times,
  preservation of the bones in an ossuary)
• Shivah week-long period of mourning in ancient
  times sprinkling of ashes, rolling on the ground,
  tearing clothes, dressing in sackcloth in modern
  times, forsaking ones everyday work and routine
• Kaddish to be said at the Yahrzeit (first
  anniversary of death)

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CHRISTIANITYThe Origin of Death

• Shared with Judaism (and later with Islam)
• Original sin of the first humans brought the
  penalty of death not only to Adam and Eve but to
  all people

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CHRISTIANITYThe most important death

• The crucifixion of Jesus
• a common means of execution of criminals in the
  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

• Centrality of the death and resurrection of Jesus
• Based on peoples eye-witness accounts of his
  death and resurrection as well as on his
  teachings, the Christian doctrine of resurrection
  was formulated
• 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
• 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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CHRISTIANITYWhat happens after we die?

• The Afterlife
• Destination determined by the individuals
  acceptance or rejection of the salvific death and
  resurrection of Jesus
• Heaven
• Eternal life for the believer in a perfected
  body
• Life in the 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 the 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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CHRISTIANITYHow is death observed?

• At and after 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
• Christian burial
• Requiem mass
• Prayers for the dead

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ISLAMThe origin and purpose of death

• The origin of death as in Judaism and
  Christianity
• the original sin of Adam and Eve, and the
  punishment In the earth you will live, and in
  it you will die Quran 7.24
• The 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
• A time of trial
• Life is a time of probation and decision while
  alive, individuals are free to direct their lives
  along the straight path back to God (sirat
  ulMustaqim) or to reject God Quran 1.5

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ISLAMWhat happens when we die?

• Human beings are body and spirit separated, then
  reunited
• Bashar flesh, the body
• Ruh Gods breath or soul with which he infuses
  the bashar and which continues to live apart from
  the body after death until its reunion with the
  body on the Day of Resurrection
• Nafs the spiritual vitality linking body and
  soul, which escapes at the time of death (and
  also departs the body at night in sleep and
  returns in the morning) Quran 6.60f

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ISLAMWhat happens after we die?

• The angel of death gathers those who are due to
  die Quran 32.10/9-11
• The body is buried and decays
• The soul escapes the body and may either be
  raised into an interim body or be in a suspended
  state
• The body and soul are reunited on the Day of
  Resurrection (yaum ulQiyama) we will raise him
  up on the day of resurrectionQuran 20.125
• The appearance before God on the Day of Judgment
  (yaum udDin)

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ISLAMJudgment and the 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 the misdeeds
  of another (contra Christianity)
• The Garden of Reward for the ones who turn to
  God during life (eternal pleasure)
• The Fire of Jahannam for those who reject God
  during life (eternal burning with fire)

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ISLAMHow is death observed?

• Washing and burying the body within 8 hours of
  death
• Respect for the body (because it will be restored
  on the Day of Resurrection)
• Prayers over the dead (the four takbirs
  proclamations of Gods greatness)
• Recitation of the whole Quran if possible
• Mourning should not be excessive, as this would
  disturb the dead as well as show lack of
  acceptance of Gods will and purpose regarding
  death

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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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HINDUISMThe soul is eternal

• Souls are eternal and do not die with the body
  as Krishna said,
• 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
• To attain this condition of wisdom about the
  souls eternality is to attain brahman

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HINDUISMThe goal is to free the self

• Brahman/nirvana the freed self who has attained
  a state of wisdom regarding the eternality of the
  soul
• A state of power experienced both in this life
  and after death
• Liberation achieved by renouncing all desired
  objects and not experiencing any cravings for
  them, absence of preoccupation with the bodily
  self Gita 2.71f
• The state of happiness and peace from being
  eternally with Krishna (and yet distinct from
  him)

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HINDUISMThe cycle of death and rebirth

• The self is unchanged, yet reborn repeatedly
  until it finds it way to liberation using the
  Gita and other scriptures as a guide
• Samsara the cycle of rebirth which continues
  until brahman/nirvana is reached
• Karma actions and their consequences bad karma
  can only be overcome by achieving moksha, or the
  release that comes when one realizes that one
  cannot influence the process of karma
• Kashi dying in the right city is a shortcut to
  moksha

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HINDUISMDeath is not that important

• During samsara death will occur many times thus
  it is of little importance
• One death is merely a stage, a milestone, in a
  long process
• The continuing self has already passed on when a
  person dies (or is cremated)
• if one is good, the soul leaves through the
  brahmarandhra (a small opening in the crown of
  the head) if one is evil, through the anus

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HINDUISMThe afterlife before reentering samsara

• Preta an intermediate condition taken by the
  soul immediately after death
• Judgment and the afterlife
• Early literature the domain of Yama, the ruler
  of the ancestors a place where families are
  reunited and the pain and sorrow of this life is
  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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HINDUISMHow is death observed?

• Meditation on God at the time of death
• the soul can influence what form it will take
  next
• aided by namakirtana, or chanting the name of a
  god until one ceases to be aware of anything else
• Ritual return of the dead on the funeral pyre
• the eye to the sun, the breath (atman) to the
  wind, the body to the plants Rg Veda 10.16.3
• Ekoddista ritual to render benign the 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
• to construct an interim body for the preta

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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, the doctors presence at the
  deathbed was rare this was the priests role
• When involved at all, the doctors role was
  merely to predict the time of death (so the
  priest could do his job)
• After the Enlightenment, it became a status
  symbol to die under medical care, as medicine
  was seen to be able to do battle with death
• Dissection enabled improved understanding of
  pathophysiology of death
• Diseases were being described and categorized
• New vision of natural death was thus available
  death at the end of a long life as the result of
  a clinically identifiable illness
• Death may 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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Death as Biological Imperative

• Cells are preprogrammed to stop dividing after a
  certain number of divisions, and then to die
  (apoptosis)
• DNA errors accumulate over time and 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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Medical Definitions of DeathCardiopulmonary Death

• Previously easily diagnosed by irreversible
  cessation of respiration and circulation which
  necessarily led to death of all organs within a
  short time
• After advent of ventilators, death could not be
  equated with absence of vital signs of
  circulation and respiration since machines can
  fulfill these functions
• If this definition of death was used, organ
  harvesting for transplants would be jeopardized
  by deterioration of the organs during the time
  immediately after cessation of respiration and
  circulation
• Currently accepted in the USA as one of two valid
  definitions of death
• A Scholthauer and B Liang, Definitions and
  implications of death. Hematology/oncology
  Clinics of North America 166 (2002).

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Medical 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 is first state to legally recognize
  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

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Medical Definitions of DeathWhole-Brain Death

• This definition means that healthy organs can be
  harvested as artificial ventilation and
  respiration are maintained
• It also implies that once a diagnosis of
  whole-brain death is made, further medical
  treatment is futile this has financial
  implications medical insurance generally will
  not cover that is not medically necessary,
  leaving families and hospitals with the bill for
  further treatment
• USA, Germany, Japan, and France all accept this
  definition of death

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Medical Definitions of DeathHigher-Brain Death

• Applicable to PVS patients those without brain
  functions that control emotion, cognition and
  consciousness but who maintain at least partial
  brain stem function
• In general, courts are reluctant to adopt this
  definition because the absence of higher,
  cortical brain activity is harder to prove with
  certainty, at least in the short term
• However, some courts have allowed
  life-sustaining treatment of PVS patients to be
  discontinued (e.g., Quinlan, Cruzan, Schiavo?)

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Modern Medical Death Rites

• Life insurance to ameliorate the consequences of
  ones death, to gain greater control over death
• Wills to determine what happens to ones
  possessions after death
• Death certificates to enshrine in law the cause
  of death
• Autopsies to identify the cause of death if not
  obvious
• Inquests to identify the cause of death if
  suspected to be unnatural
• Burial of the body (/- embalming) OR cremation
  and interment of ashes to confine the deceased
  to a known resting place which can also serve
  as a memorial

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Death in Society Doctors and Patients

• Nationality
• Ethnicity
• Class

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DOCTORSDifferences in End-of-life Care

• Death in ICU preceded by decision to limit care
• Belgium 65
• Canada 70
• USA 75
• Israel 91
• Decisions to withhold versus withdraw care (in a
  survey 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) were less
  likely to withdraw life support
• Withdrawal of nutrition is considered acceptable
  in PVS patients
• USA 89
• Britain 65
• Belgium 56
• Japan 17
• J-L Vincent, Cultural differences in end-of-life
  care. Critical Care Medicine 292 (2001).

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PATIENTSDifferences in End-of-Life Decisions

• Nationality
• Canadian patients more likely to want the details
  of their terminal illness than patients in Europe
  or South America
• J-L Vincent, Cultural differences in end-of-life
  care. Critical Care Medicine. 292 (2001).

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PATIENTSDifferences in End-of-Life Decisions

• Ethnicity
• Cultures which are more individualistic, secular,
  pragmatic, scientific tend to prefer full open
  awareness (as 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 the
  dying Japanese
• Most wills and life insurance Anglos
• C Seale. Constructing Death. Cambridge CUP,
  1998, pp. 179-181.

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PATIENTSDifferences in End-of-Life Decisions

• Ethnicity
• In USA, whites significantly more likely than
  blacks
• to discuss treatment preferences before death
• to complete a living will
• 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).

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PATIENTSDifferences in End-of-Life Decisions

• Class
• Persons of higher socioeconomic class 2.7 times
  more likely to desire full open awareness of a
  terminal diagnosis
• C Seale. Constructing Death. Cambridge CUP,
  1998, p. 179

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The Individual

• My Death

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I Will Die

• What is required to understand the notion, I
  will die? To bridge the gap between what Ive
  experienced of life to a construct of its
  negation?
• 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.

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Death and Psychological Development

• Developmental Stages
• Up to age 5
• Death is not final
• Death is a diminution of aliveness
• Death involves separation
• Ages 5-9
• Death is final
• Death is not inevitable if one is clever and
  lucky
• Death personification death as a separate
  person
• Age 10 and older
• Death is final
• Death is inevitable
• Death is universal
• Nagy, in R Kastenbaum. The Psychology of Death.
  New York Springer, 2000, pp. 51-53.

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Stages of Dying

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

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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 preempted 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.