Death and dying in contemporary societyan evaluation of current attitudes and the rituals associated with death and dying and their relevance to recent understanding of health and healing

Journal of Advanced Nursing. 1998, 27, 1127-1135 Death and dying in contemporary society: an evaluation of current attitudes and the rituals associated with death and dying and their relevance to recent understandings of health and healIng Stella Mary O'Gorman BA(Hons)DPSN RGN RMN 46 Poll Hill Road, Heswall, Wirral L60 7XW. england Accepted for publication 8 June 1997 O'GORMAN S.M. (1998) Journal of Advanced Nursing 27, 1127-1135 Death and dying in contemporary society: an evaluation of current attitudes and the rituals associated with death and dying and their relevance to recent understandings of health and he This paper develops a model which is intended to help nurses and other health professionals in the understanding of contemporary views regarding death and dying and the associated issues of health and healing. The author contends that in the first half of the 20th century, society lost sight of the importance of rituals associated with death and dying and of the need for appropriate death ducation. Consequently patients and professionals alike found themselves unable to cope with the inevitability of death. Fear supplanted hope, and the health and well-being of society was deleteriously influenced. During the second half of th y, there has been a proliferation of thanatology research and literature. Health professionals are realizing the inadequacy of their knowledge of an issue which fundamentally and unavoidably affects everyone including themselves. The holistic approach to health care has been recognized by many researchers as being essential to health and healing, and therefore death and dying have to be addressed. Often nurses are the professionals left to deal with the patients' grief and anger, and it is therefore critical that they are conversant with the contemporary parallel issues of death and dying and health and healing. The author also firmly believes that before nurses can help people to overcome the fear of death and to optimize their lives, it is essential to examine the traditions of other cultures as well as personal experiences and coping mechanisms, before an understanding of other people' s fears and beliefs concerning death and dying can be reached Keywords: death, dying, society, modern, primitive, rituals, funerals, mourning, holistic education INTRODUCTION views will be examined from social, professional, and indi- vidual and family aspects. A model will be developed This paper will begin by establishing the current attitudes based on Illich (1990)Sweeting and Gilhooley(1992) to death and dying. The historical development of these which will set out the sequence of these developments @1998 Blackwell Science Ltd 1127

Journal of Advanced Nursing, 1998, 27, 1127–1135 Death and dying in contemporary society: an evaluation of current attitudes and the rituals associated with death and dying and their relevance to recent understandings of health and healing Stella Mary O’Gorman BA(Hons) DPSN RGN RMN 46 Poll Hill Road, Heswall, Wirral L60 7XW, England Accepted for publication 8 June 1997 O’GORMAN S.M. (1998) Journal of Advanced Nursing 27, 1127–1135 Death and dying in contemporary society: an evaluation of current attitudes and the rituals associated with death and dying and their relevance to recent understandings of health and healing This paper develops a model which is intended to help nurses and other health professionals in the understanding of contemporary views regarding death and dying and the associated issues of health and healing. The author contends that in the first half of the 20th century, society lost sight of the importance of rituals associated with death and dying and of the need for appropriate death education. Consequently patients and professionals alike found themselves unable to cope with the inevitability of death. Fear supplanted hope, and the health and well-being of society was deleteriously influenced. During the second half of the century, there has been a proliferation of thanatology research and literature. Health professionals are realizing the inadequacy of their knowledge of an issue which fundamentally and unavoidably affects everyone including themselves. The holistic approach to health care has been recognized by many researchers as being essential to health and healing, and therefore death and dying have to be addressed. Often nurses are the professionals left to deal with the patients’ grief and anger, and it is therefore critical that they are conversant with the contemporary parallel issues of death and dying and health and healing. The author also firmly believes that before nurses can help people to overcome the fear of death and to optimize their lives, it is essential to examine the traditions of other cultures as well as personal experiences and coping mechanisms, before an understanding of other people’s fears and beliefs concerning death and dying can be reached. Keywords: death, dying, society, modern, primitive, rituals, funerals, mourning, holistic, education views will be examined from social, professional, and indi- INTRODUCTION vidual and family aspects. A model will be developed This paper will begin by establishing the current attitudes based on Illich (1990) Sweeting and Gilhooley (1992) to death and dying. The historical development of these which will set out the sequence of these developments © 1998 Blackwell Science Ltd 1127

S.M. GOrman Stages in the process of social death in'primitive' societies 15th century eath become autono Period 16-17th ce death becomes independent Living ancestor 17-18th century ' Bourgeois Death death avoidance by paying for health the emergence of the scientific doctor Stages in the process of social death in modem westem societie nitial Period New Stage 5 20th century 'Health as a commodity status status health is seen as a civil right Livin ve care contemporary society unable to cope -} Professionalization of death rituals. sweeting and Gilhooley paradigm (1992) institutional ization Figure 2 Rituals associated with death and dying. Reproduced with permission from Sweeting and Gilhooly (1992) orary education endorses This concept is shaped by institutional structures, deep at the time. These changes are seen throughout history and (Figure 1). The relevance of recent understandings of their effects upon society, different professional groups health and healing to current attitudes concerning of a'natural'death in old age after years of good healhig individuals and families can be demonstrated. The im and dying will be illustrated by the model One perspective will be chosen from the developed a recent ideal Illich (1990) presents a theory that this view nodel for more detailed study. Rituals associated with of health and healing and death and dying has evolved death and dying will be discussed with reference to over 500 years in five distinct phases and is about to enter Sweeting and Gilhooley,s paradigm (1992)(Figure 2). a sixth(Figure 1). Each stage can be substantiated by Again the perspective will be evaluated critically from the artistic representations and the work of other writers social, professional, individual and family aspects, and the relevance to recent understandings of health and healing Dance of the dead considered The author will reflect on personal experience of rituals associated with death and dying with compari- Illich(1990)states that the ' Stage 1 in the evolution of sons of English and rural Irish encounters our ideas regarding death began in the middle ages. The he conclusion will discuss the negative and positive 15th Century Dance of the Dead, depicted by artists shows germane factors for the better understanding of death and was represented as a macabre self-consciousness and a dying and its relevance to health and healing had been regarded as the deliberate personal intervention of God. Illich(1990) maintains that this change to death DEVELOPMENT OF CURRENT ATTITUDES becoming autonomous and part of human life rather than TO DEATH AND DYING due to the intervention of a foreign agent. led to a coexist- Illich(1990) claims that in every society the dominant ence of death as a separate agent with the immortal soul image of death determines the prevalent concept of health. divine providence and angels and demons. He proposes 1128 @1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127-113

S.M. O’Gorman Stages in the process of social death in ‘primitive’ societies Stages in the process of social death in modern western societies Initial social status Living person Living person Hospital patient Body and soul in limbo Dead ancestor Rituals marking biological death Rituals of admission: hospitalization and/or institutionalization Anticipatory grief Social death Biological death and rituals of mourning Rituals of mourning Rituals of social death Soul in limbo Dead ancestor Period of transition New social status Initial social status Period of transition New social status Figure 2 Rituals associated with death and dying. Reproduced with permission from Sweeting and Gilhooly (1992). Stage 1 15th century ‘Dance of the Dead’ — death become autonomous Stage 2 16–17th century ‘Dance of Death’ — death becomes independent Stage 3 17–18th century ‘Bourgeois Death’ — death avoidance by paying for health Stage 4 19th century ‘Clinical Death’ — the emergence of the scientific doctor Stage 5 20th century ‘Health as a commodity’ — health is seen as a civil right Stage 6 ‘Death in intensive care’ — contemporary society unable to cope with death and dying Late 20th century - Changes in attitudes Stage 7 ‘Social Death’ — Professionalization of death rituals. Sweeting and Gilhooley paradigm (1992) (Figure 2) Stage 8 ‘Return to holistic concepts’ — contemporary education endorses understanding of death as ‘right of passage’ This concept is shaped by institutional structures, deep Figure 1 Stages in development of current attitudes to death and seated myths and the social character which predominates dying. at the time. These changes are seen throughout history and their effects upon society, different professional groups, (Figure 1). The relevance of recent understandings of individuals and families can be demonstrated. The image health and healing to current attitudes concerning death of a ‘natural’ death in old age after years of good health is and dying will be illustrated by the model. a recent ideal. Illich (1990) presents a theory that this view One perspective will be chosen from the developed of health and healing and death and dying has evolved model for more detailed study. Rituals associated with over 500 years in five distinct phases and is about to enter death and dying will be discussed with reference to a sixth (Figure 1). Each stage can be substantiated by Sweeting and Gilhooley’s paradigm (1992) (Figure 2). artistic representations and the work of other writers. Again the perspective will be evaluated critically from the social, professional, individual and family aspects, and the relevance to recent understandings of health and healing Dance of the dead considered. The author will reflect on personal experience Illich (1990) states that the ‘Stage 1’ in the evolution of of rituals associated with death and dying with compari- our ideas regarding death began in the middle ages. The sons of English and rural Irish encounters. 15th Century ‘Dance of the Dead’ depicted by artists shows The conclusion will discuss the negative and positive each person dancing with a mirror image of himself. Death elements demonstrated in these reflections and extrapolate was represented as a macabre self-consciousness and a germane factors for the better understanding of death and constant awareness of the gaping grave. Until then death dying and its relevance to health and healing. had been regarded as the deliberate personal intervention of God. Illich (1990) maintains that this change to death DEVELOPMENT OF CURRENT ATTITUDES becoming autonomous and part of human life rather than TO DEATH AND DYING due to the intervention of a foreign agent, led to a coexist￾Illich (1990) claims that in every society the dominant ence of death as a separate agent with the immortal soul, image of death determines the prevalent concept of health. divine providence and angels and demons. He proposes 1128 © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127–1135

Death and dying in contemporary society that this represents a readiness by the society of that time for a radical change in attitudes and for death to become Bourgeois death a 'natural event Stage 3in Ilich's (1990) theory is called Bourgeois Death,In the 'Dance of death' the mower was seen using Dance of death his scythe regardless of the rank of the individual. Th Industrial Revolution began to create employment and Illich,s(1990)'Stage 2' is highlighted by the 'Dance of wealth, an enlarged bourgeoisie and a society which was Death(The Danse Macabre). Helgeland (1985)finds this beginning to want good health into old age(Illich 1990, image in poetry and sculpture all over Europe and the Foucault 1991). The 17th century onwards shows the rise British islands and refers to Holbein(1971)depicting every of the bourgeois family and those who could afford it began person accompanied by the figure of death, represented by to pay to keep death away. To die whilst courting a grand- a skeleton Helgeland(1985)maintains that from the 12th son's mistress was an enviable goal (Illich 1990). Foucault entury onwards the death of a cultural system with many (1991)dates from this time the current organization of dis- of its institutions is represented in society s preoccupation ease as a political and economic problem for social collec- with death. He is of the view that'the dance'depicts the tivities to resolve as a matter of overall policy. The health death of the old society, class ridden, with honour as its of a nation became relevant factors in economic manage- pivotal criterion, and the birth of dignity for all humanity ment. An apparatus ensuring the constant increase of a ivested of socially imposed roles or norms. Illich (1990) population,s usefulness had to be organized. Death was subscribes to the view that the dance represents a change regarded as an'untimely event when it came to those who from death being a transition into the next world to the were not both healthy and old accent being placed on the end of this life, and that as Foucault(1991) states that the medical market - the institutions gave way in the Middle Ages people were extension of a network of personnel offering qualified thrown back on themselves to provide their own meaning medical attention- started in the 18th century. Illich and purpose in life. Death became a ' force of naturewith (1990) is dubious of the worth of the treatment given at which to do battle that time, but medical care for protracted illness had In the early Middle Ages the most influential pro- become a mark of distinction. The state began to dismantle fessional group of the time was the church. The the old charitable institutions and allowed the doctor to Reformation undermined this power and according to become the social and political reformer of the late 18th Helgeland (1985)the dispossessed mendicant monks left century(Foucault 1991) their cloisters for the roads and cities, and were the great Foucault(1991)and Illich(1990 )note the changes in the isseminators of"the dance, warning that all society was status of the family which is now assigned a linking role under attack in an age of transition. Illich(1990)tells us between general objectives regarding the good health of that doctors at this time could assist healing or help the the social body and the individuals desire or need for coming of an easy and speedy death. Any attempt to pro- care. The ethic of good health becomes the duty of parents long life was regarded as blasphemous (Illich 1990) and children to uphold. A qualified professional body of McNeill (1976)theorized that the Black Death changed doctors recommended by the state supplies the necessary the course of history and the individual's view of his own knowledge. The middle classes employ doctors to tell mortality. Helgeland (1985)rejects this idea, arguing that death when to strike the social turmoil at the time could itself have been the cause of the plague. Certainly people became increasingly Clinical death dependent upon themselves rather than their shaky inst tutions and the death of a person became all the more Illich's(1990) Stage 4, 'Clinical Death, places the doctor shattering and frightening for the individual (Tuchman centre stage struggling against the roaming phantoms of 1978). People turned to secular advice such as the Ars consumption and pestilence. Books of the late 19th cen- Moriendi. O'Connor(1966) discusses the development of tury show the doctor battling with personified diseases at the Ars Moriendi as a complete guide to the business of the bedside of his patient Death had become the outcome dying well. How a person had lived became secondary to of specific diseases certified by the doctor. Shryock(1947) how one died. Folk practices and superstitions developed notes that the hope of doctors to control the outcome of which could be employed to ensure a good death. By the diseases gav rise to the myth that they had power over end of the 17th century the corpse was no longer sacred death. The new powers attributed to the profession gave as before, and public dissection became a subject for a new status to the clinician. By the mid-19th century he aintings and carnivals(Illich 1990) had become a member of the now powerful middle class Shyrock (1947)describes this new role of playing lacke the squire, a family friend to other notables, paying occasional visits to the sick and sending complicated cases 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127-1135 1129

Death and dying in contemporary society that this represents a readiness by the society of that time Bourgeois death for a radical change in attitudes and for death to become a ‘natural event’. ‘Stage 3’ in Illich’s (1990) theory is called ‘Bourgeois Death’. In the ‘Dance of Death’ the mower was seen using his scythe regardless of the rank of the individual. The Dance of death Industrial Revolution began to create employment and Illich’s (1990) ‘Stage 2’ is highlighted by the ‘Dance of wealth, an enlarged bourgeoisie and a society which was Death’ (The Danse Macabre). Helgeland (1985) finds this beginning to want good health into old age (Illich 1990, image in poetry and sculpture all over Europe and the Foucault 1991). The 17th century onwards shows the rise British islands and refers to Holbein (1971) depicting every of the bourgeois family and those who could afford it began person accompanied by the figure of death, represented by to pay to keep death away. To die whilst courting a grand￾a skeleton. Helgeland (1985) maintains that from the 12th son’s mistress was an enviable goal (Illich 1990). Foucault century onwards the death of a cultural system with many (1991) dates from this time the current organization of dis￾of its institutions is represented in society’s preoccupation ease as a political and economic problem for social collec￾with death. He is of the view that ‘the dance’ depicts the tivities to resolve as a matter of overall policy. The health death of the old society, class ridden, with honour as its of a nation became relevant factors in economic manage￾pivotal criterion, and the birth of dignity for all humanity ment. An apparatus ensuring the constant increase of a divested of socially imposed roles or norms. Illich (1990) population’s usefulness had to be organized. Death was subscribes to the view that ‘the dance’ represents a change regarded as an ‘untimely event’ when it came to those who from death being a transition into the next world to the were not both healthy and old. accent being placed on the end of this life, and that as Foucault (1991) states that the medical market — the institutions gave way in the Middle Ages people were extension of a network of personnel offering qualified thrown back on themselves to provide their own meaning medical attention— started in the 18th century. Illich and purpose in life. Death became a ‘force of nature’ with (1990) is dubious of the worth of the treatment given at which to do battle. that time, but medical care for protracted illness had In the early Middle Ages the most influential pro- become a mark of distinction. The state began to dismantle fessional group of the time was the church. The the old charitable institutions and allowed the doctor to Reformation undermined this power and according to become the social and political reformer of the late 18th Helgeland (1985) the dispossessed mendicant monks left century (Foucault 1991). their cloisters for the roads and cities, and were the great Foucault (1991) and Illich (1990) note the changes in the disseminators of ‘the dance’, warning that all society was status of the family which is now assigned a linking role under attack in an age of transition. Illich (1990) tells us between general objectives regarding the good health of that doctors at this time could assist healing or help the the social body and the individual’s desire or need for coming of an easy and speedy death. Any attempt to pro- care. The ethic of good health becomes the duty of parents long life was regarded as blasphemous (Illich 1990). and children to uphold. A qualified professional body of McNeill (1976) theorized that the Black Death changed doctors recommended by the state supplies the necessary the course of history and the individual’s view of his own knowledge. The middle classes employ doctors to tell mortality. Helgeland (1985) rejects this idea, arguing that death when to strike. the social turmoil at the time could itself have been the cause of the plague. Certainly people became increasingly Clinical death dependent upon themselves rather than their shaky insti￾tutions and the death of a person became all the more Illich’s (1990) Stage 4, ‘Clinical Death’, places the doctor shattering and frightening for the individual (Tuchman centre stage struggling against the roaming phantoms of 1978). People turned to secular advice such as the Ars consumption and pestilence. Books of the late 19th cen￾Moriendi. O’Connor (1966) discusses the development of tury show the doctor battling with personified diseases at the Ars Moriendi as a complete guide to the business of the bedside of his patient. Death had become the outcome dying well. How a person had lived became secondary to of specific diseases certified by the doctor. Shryock (1947) how one died. Folk practices and supersititions developed notes that the hope of doctors to control the outcome of which could be employed to ensure a good death. By the diseases gave rise to the myth that they had power over end of the 17th century the corpse was no longer sacred death. The new powers attributed to the profession gave as before, and public dissection became a subject for a new status to the clinician. By the mid-19th century he paintings and carnivals (Illich 1990). had become a member of the now powerful middle class. Shyrock (1947) describes this new role of playing lackey to the squire, a family friend to other notables, paying occasional visits to the sick and sending complicated cases © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127–1135 1129

S.M. GOrman to his clinical colleague in town in one of the new special- states that we go to extraordinary lengths not to refer ist hospitals. Foucault (1991)cites how the Middlesex directly to death. He mentions elaborate euphemisms such Hospital opened in London, England, in 1745 for the treat- as'passed away'or'departed this life,. Barley (1995)finds ment of smallpox and the practice of vaccination, and the society adapts euphemisms so as not to disrupt the flow London Fever Hospital opened in 1802. Illich(1990) main- of conversation. In the language of the politician or tains that clinical death'originated in the emerging pro- upwardly mobile manager death is'failing to fulfil one's fessional consciousness of the new scientifically trained wellness potentialor'suffering a terminal inconvenience. doctor In Bolivia a dead person will have 'gone to cultivate chilli peppe s a commo Illich(1990)tells us 19th century art depicts death taking Social death the initiative in dealing with the doctor or the sick, Sweeting and Gilhooley's(1992)paradigm investigates the whereas that of the 20th century shows the doctor taking differences between the rituals seen in so-called'primitive the lead and interposing himself between his patient and societies and those of Western cultures. Due to pro- death. Illich (1990) proposes that this represents 'Stage 5 fessionalization of the rituals of death and dying an indi- in society's concept of death. Individuals began to see vidual can be socially dead before being biologically dead death whilst undergoing treatment by clinically trained It will be suggested in this paper that social death is Stage 7 doctors as a civil right (illich 1990). By the middle of the in the developed model and is directly due to the grieving 20th century, Seedhouse(1992), Illich(1990), Sacks(1982) process and its associated rituals no longer being observed and Dubos(1959) acknowledge the fact that health has and intellectual strength of the human race which enables Return to holistic concepts em to rise to the challenges of dying and death. Nevertheless, Illich,'s(1990)depressing description of the contemporary view of health and its divorce from and pre- Death in intensive care credence over death and dying has been challenged by other authors since its original publication in 1976. Rece Illich's(1990)'Stage 6' is epitomized by the patient in a literature supports the theory that attitudes to death and critical condition in the intensive care ward of a hospital. dying have changed dramatically over the second half of Protected against dying and defeated by the victory of this century and society is adopting more holistic views medicalization over society, the patient is no longer able (Wahl 1959, Elias 1985, Bertman 1991, Mellor 1993 to set the scene for his own death; nor can the professionals Rinpoche 1995) who have taken control of life and death agree amongst Ramsey wrote in 1974: There is a growing agreement themselves what actually constitutes death(Sweeting amongst moralists that death has again to be accepted and Gilhooley 1992). Moreover, doctors and nurses consider all that can be done for the dying is to keep them company themselves to have failed if a patient dies(Pietroni 1991 ). in their final moments. About this time Elizabeth Kubler- Acring (1971) found that doctors were more afraid of death Ross(1970)began her multidisciplinary seminars on the than a control group of patients. Kubler-Ross (1970 )disco- care of the dying patient. She proved that with uncon vered that when professionals identified that a patient was ditional love and a more enlightened attitude, dying can dying, they withdrew from the bedside because they were be a peaceful even transformative experience. Greyson unable to cope with the process of death themselves, (1989), Moody Perry (1988)and Ring(1985) show that let alone support the patient in his final moments. near death experiences(NDE) have given humanity the At the turn of the century in Britain, death was a com- hope that life does not end with death and there is a life monplace event. Fewer people reached old age, many died after life which should not be feared. Parkes(1986) classic of incurable diseases, the rate of infant mortality was high work amongst widows and widowers acknowledges that (Ham 1994, Draper 1991). Wahl (1959)believes that death cannot be ignored because it has a profound effect through knowledge of medicine, man has succeeded in on those who are left behind in this world, causing anxiet gaining for himself an average 36.7 years of extra life. Ham depression and physical illness (1994)claims that increased life expectancy was brought Rinpoche(1992)and Pietroni(1991)agree that the hos- about through the developments in the system of public pice movement pioneered by Dame Cicely Saunders (1979) health. Whatever justification is put forward for our at least attempts to address the inadequacies and difficult increased life span, Barley (1995), Illich (1990)and ies encountered by patients, relatives and the staff caring Helgeland (1985) subscribe to the view that our preoccu- for the terminally ill, 70% of which Pietroni (1991)tells pation with health and living has repressed any meaning- us die in institutions. Rinpoche(1992), however, states ful acceptance of or preparation for death. Wahl (1959) that practical and emotional care is not enough. People 1130 @1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127-113

S.M. O’Gorman to his clinical colleague in town in one of the new special- states that we go to extraordinary lengths not to refer ist hospitals. Foucault (1991) cites how the Middlesex directly to death. He mentions elaborate euphemisms such Hospital opened in London, England, in 1745 for the treat- as ‘passed away’ or ‘departed this life’. Barley (1995) finds ment of smallpox and the practice of vaccination, and the society adapts euphemisms so as not to disrupt the flow London Fever Hospital opened in 1802. Illich (1990) main- of conversation. In the language of the politician or tains that ‘clinical death’ originated in the emerging pro- upwardly mobile manager death is ‘failing to fulfil one’s fessional consciousness of the new scientifically trained wellness potential’ or ‘suffering a terminal inconvenience’. doctor. In Bolivia a dead person will have ‘gone to cultivate chilli pepper’. Health as a commodity Social death Illich (1990) tells us 19th century art depicts death taking the initiative in dealing with the doctor or the sick, Sweeting and Gilhooley’s (1992) paradigm investigates the whereas that of the 20th century shows the doctor taking differences between the rituals seen in so-called ‘primitive’ the lead and interposing himself between his patient and societies and those of Western cultures. Due to pro￾death. Illich (1990) proposes that this represents ‘Stage 5’ fessionalization of the rituals of death and dying an indi￾in society’s concept of death. Individuals began to see vidual can be socially dead before being biologically dead. death whilst undergoing treatment by clinically trained It will be suggested in this paper that social death is Stage 7 doctors as a civil right (Illich 1990). By the middle of the in the developed model and is directly due to the grieving 20th century, Seedhouse (1992), Illich (1990), Sacks (1982) process and its associated rituals no longer being observed. and Dubos (1959) acknowledge the fact that health has become a commodity undermining the unique spiritual Return to holistic concepts and intellectual strength of the human race which enables them to rise to the challenges of dying and death. Nevertheless, Illich’s (1990) depressing description of the contemporary view of health and its divorce from and pre￾cedence over death and dying has been challenged by Death in intensive care other authors since its original publication in 1976. Recent Illich’s (1990) ‘Stage 6’ is epitomized by the patient in a literature supports the theory that attitudes to death and critical condition in the intensive care ward of a hospital. dying have changed dramatically over the second half of Protected against dying and defeated by the victory of this century and society is adopting more holistic views medicalization over society, the patient is no longer able (Wahl 1959, Elias 1985, Bertman 1991, Mellor 1993, to set the scene for his own death; nor can the professionals Rinpoche 1995). who have taken control of life and death agree amongst Ramsey wrote in 1974: ‘There is a growing agreement themselves what actually constitutes death (Sweeting & amongst moralists that death has again to be accepted and Gilhooley 1992). Moreover, doctors and nurses consider all that can be done for the dying is to keep them company themselves to have failed if a patient dies (Pietroni 1991). in their final moments’. About this time Elizabeth Kubler￾Acring (1971) found that doctors were more afraid of death Ross (1970) began her multidisciplinary seminars on the than a control group of patients. Kubler-Ross (1970) disco- care of the dying patient. She proved that with uncon￾vered that when professionals identified that a patient was ditional love and a more enlightened attitude, dying can dying, they withdrew from the bedside because they were be a peaceful even transformative experience. Greyson unable to cope with the process of death themselves, (1989), Moody & Perry (1988) and Ring (1985) show that let alone support the patient in his final moments. near death experiences (NDE) have given humanity the At the turn of the century in Britain, death was a com- hope that life does not end with death and there is a life monplace event. Fewer people reached old age, many died after life which should not be feared. Parkes’ (1986) classic of incurable diseases, the rate of infant mortality was high work amongst widows and widowers acknowledges that (Ham 1994, Draper 1991). Wahl (1959) believes that death cannot be ignored because it has a profound effect through knowledge of medicine, man has succeeded in on those who are left behind in this world, causing anxiety, gaining for himself an average 36·7 years of extra life. Ham depression and physical illness. (1994) claims that increased life expectancy was brought Rinpoche (1992) and Pietroni (1991) agree that the hos￾about through the developments in the system of public pice movement pioneered by Dame Cicely Saunders (1979) health. Whatever justification is put forward for our at least attempts to address the inadequacies and difficult￾increased life span, Barley (1995), Illich (1990) and ies encountered by patients, relatives and the staff caring Helgeland (1985) subscribe to the view that our preoccu- for the terminally ill, 70% of which Pietroni (1991) tells pation with health and living has repressed any meaning- us die in institutions. Rinpoche (1992), however, states ful acceptance of or preparation for death. Wahl (1959) that practical and emotional care is not enough. People 1130 © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127–1135

Death and dying in contemporary society need something more profound. They need to embrace the its orientation to death and mourning-'kavod hamet ' the holistic perspective of contemporary health and healing requirement to honour the dead and nichum avelim' the and discover a meaning to death and to life. obligation to comfort the mourners. Both of these are to be Ikeda(1988)tells us that the long-cherished Christian found in each of the specific rites of mourning ethic has effectively vanished leaving society distinctly Cytron's(1993)description of the Orthodox Jewish rit- a-religious and even amoral and with confused ideas uals begins as death draws near and the dying person and regarding health and death. Ikeda(1988) states that we family take part in farewell rites. The dying ask forgiveness need to make choices -either to revise the old Christian for their errors and express hope for the welfare of the values or adopt new sets of values better suited to our survivors. The family say final goodbyes and recite times. The interest in complementary therapies during the together prayers of affirmation and hope. As soon as death last 30 years or so, demonstrates that people are increas- has occurred the body is prepared for burial by ' chevra ingly challenging the monopoly of power of the medical kadisha, a holy society made up of specially trained lay profession over health issues(Pietroni 1991). Humanistic volunteers. Tahara'or preparation of the body entails psychology emphasizes human choice, creativity and self- washing of the body and draping it in a simple linen gar- actualization(Maddi Costa 1972). The resurgence of the ment. The body is then placed in a plain coffin so as not primordial healer or shaman and the renewed interest in to impede the natural decomposition - cremation is still Buddhism in the western world indicates a search for a frowned upon by the Jews. Sweeting and Gilhooley (1992) sense of meaning and purpose in the universe(Ikeda 1988, would consider these rites marking the biological death of Money 1994). Christians themselves are adapting to the a person changes and embracing the holistic approach of east- The rituals of mourning begin during this period of ern philosophies in which peace and compassion and transition from biological to social death. Because the body meditation are valued (Mello 1983) is now thought to be vulnerable and the soul in limbo, it the moment we all remain in a state of transition, is watched over until the 'homecoming or final resting moving from a pre-occupation with health which left us place in the earth from where it is perceived to have unprepared for death, to realization that death is inevitable originated for all of us and that in coming to terms with this fact we The Jewish funeral service begins with the cutting of can enhance our lives. The author puts this forward as garments to symbolize the individual being cut away from Stage 8(Figure 1)in the development of contemporary loved ones( Cytron 1993, Barley 1995). In the synagogue attitud psalms of comfort are read at the funeral followed by eulogy about the individual's life. The burial is often in RITUALS ASSOCIATED WITH DEATH AND family plot, those who can afford to do so have the body DYING transported to be buried on the Mount of Olives outside Jerusalem. Failing this, earth from Israel is placed in the This section of the paper examines the use of rituals in coffin acknowledging the deep yearning to be buried in association with death and dying and how changes in prac- the land of Israel. At the grave side the 'kaddish' the home- tices have affected contemporary society. Stage 7 in the coming prayer is recited affirming death while acceptin model (Figure 1)will be developed using Sweeting and life. The family then returns home for a special meal of Gilhooley's(1992) paradigm(Figure 2) consolation which often includes eggs which are a sign of life and death and rebirth in many religious traditions Rituals in'primitive'societies Mourning in Orthodox Judaism continues with shiva In most non-western societies death is not seen as a single 7 days during which the bereaved remain at home and are event, but as a process, the deceased slowly being trans- visited by friends. Cytron(1993)discovered the value of ferred from the land of the living to that of the dead this ritual after the death of his father when many people (Helman 1985, Sweeting Gilhooly 1992, Barley 1995). visited them at home and talked about what his father had This process is illustrated by rituals marking biological meant to them, which in turn empowered the family to death, followed by rituals of mourning and then rituals of express their own feelings. Sweeting and Gilhooley (1992) social death(Figure 2). These practices can still be seen in and Cytron(1993)describe further mourning periods of 30 western society within strict religious groups such as the days and a year. Sweeting and Gilhooley(1992) relate Orthodox Jews, who are used to illustrate Sweeting and these to the social death of a person as the relatives become Gilhooley's(1992)findings. more accustomed to his death. Customs are observed Cytron(1993)and Helman (1985) describe the process during these times to suggest that their lives have been of dying adhered to by Orthodox Jews as having a precise altered by death and that they still have more grieving to structure accompanied by certain rituals. Cytron (1993) work through Mourning dress is worn until the 30th day states that there are two over-riding values at the heart of and recreation and amusement forbidden for a year. 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127-1135 1131

Death and dying in contemporary society need something more profound. They need to embrace the its orientation to death and mourning — ‘kavod hamet’ the holistic perspective of contemporary health and healing requirement to honour the dead and ‘nichum avelim’ the and discover a meaning to death and to life. obligation to comfort the mourners. Both of these are to be Ikeda (1988) tells us that the long-cherished Christian found in each of the specific rites of mourning. ethic has effectively vanished leaving society distinctly Cytron’s (1993) description of the Orthodox Jewish rit￾a-religious and even amoral and with confused ideas uals begins as death draws near and the dying person and regarding health and death. Ikeda (1988) states that we family take part in farewell rites. The dying ask forgiveness need to make choices —either to revise the old Christian for their errors and express hope for the welfare of the values or adopt new sets of values better suited to our survivors. The family say final goodbyes and recite times. The interest in complementary therapies during the together prayers of affirmation and hope. As soon as death last 30 years or so, demonstrates that people are increas- has occurred the body is prepared for burial by ‘chevra ingly challenging the monopoly of power of the medical kadisha’, a holy society made up of specially trained lay profession over health issues (Pietroni 1991). Humanistic volunteers. ‘Tahara’ or preparation of the body entails psychology emphasizes human choice, creativity and self- washing of the body and draping it in a simple linen gar￾actualization (Maddi & Costa 1972). The resurgence of the ment. The body is then placed in a plain coffin so as not primordial healer or shaman and the renewed interest in to impede the natural decomposition — cremation is still Buddhism in the western world indicates a search for a frowned upon by the Jews. Sweeting and Gilhooley (1992) sense of meaning and purpose in the universe (Ikeda 1988, would consider these rites marking the biological death of Money 1994). Christians themselves are adapting to the a person. changes and embracing the holistic approach of east- The rituals of mourning begin during this period of ern philosophies in which peace and compassion and transition from biological to social death. Because the body meditation are valued (Mello 1983). is now thought to be vulnerable and the soul in limbo, it For the moment we all remain in a state of transition, is watched over until the ‘homecoming’ or final resting moving from a pre-occupation with health which left us place in the earth from where it is perceived to have unprepared for death, to realization that death is inevitable originated. for all of us and that in coming to terms with this fact we The Jewish funeral service begins with the cutting of can enhance our lives. The author puts this forward as garments to symbolize the individual being cut away from ‘Stage 8’ (Figure 1) in the development of contemporary loved ones (Cytron 1993, Barley 1995). In the synagogue attitudes. psalms of comfort are read at the funeral followed by a eulogy about the individual’s life. The burial is often in a family plot, those who can afford to do so have the body RITUALS ASSOCIATED WITH DEATH AND transported to be buried on the Mount of Olives outside DYING Jerusalem. Failing this, earth from Israel is placed in the This section of the paper examines the use of rituals in coffin acknowledging the deep yearning to be buried in association with death and dying and how changes in prac- the land of Israel. At the grave side the ‘kaddish’ the home￾tices have affected contemporary society. Stage 7 in the coming prayer is recited affirming death while accepting model (Figure 1) will be developed using Sweeting and life. The family then returns home for a special meal of Gilhooley’s (1992) paradigm (Figure 2). consolation which often includes eggs which are a sign of life and death and rebirth in many religious traditions (Cytron 1993). Rituals in ‘primitive’ societies Mourning in Orthodox Judaism continues with ‘shiva’, In most non-western societies death is not seen as a single 7 days during which the bereaved remain at home and are event, but as a process, the deceased slowly being trans- visited by friends. Cytron (1993) discovered the value of ferred from the land of the living to that of the dead this ritual after the death of his father when many people (Helman 1985, Sweeting & Gilhooly 1992, Barley 1995). visited them at home and talked about what his father had This process is illustrated by rituals marking biological meant to them, which in turn empowered the family to death, followed by rituals of mourning and then rituals of express their own feelings. Sweeting and Gilhooley (1992) social death (Figure 2). These practices can still be seen in and Cytron (1993) describe further mourning periods of 30 western society within strict religious groups such as the days and a year. Sweeting and Gilhooley (1992) relate Orthodox Jews, who are used to illustrate Sweeting and these to the social death of a person as the relatives become Gilhooley’s (1992) findings. more accustomed to his death. Customs are observed Cytron (1993) and Helman (1985) describe the process during these times to suggest that their lives have been of dying adhered to by Orthodox Jews as having a precise altered by death and that they still have more grieving to structure accompanied by certain rituals. Cytron (1993) work through. Mourning dress is worn until the 30th day states that there are two over-riding values at the heart of and recreation and amusement forbidden for a year. © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127–1135 1131