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Table of Contents


	Preface	xv
1	As We Think About Death	3
	Not Thinking About Death: A Failed Experiment	6
	Listening and Communicating	7
	Your Self-Inventory of Attitudes, Beliefs, and Feelings	8
	Some Answers—And the Questions They Raise	13
	Attitudes, Experiences, Beliefs, Feelings	14
	How does State of Mind Affect Death-Related Behavior?	15
	Man is Mortal: But What does that have to do with Me?	17
	Anxiety, Denial, and Acceptance: Three Core Concepts	18
	Studies and Theories of Death Anxiety	18
	Major Findings from Self-Reports of Death Anxiety	19
	How Much do We Fear Death?	19
	Are there Gender Differences in Death Anxiety?	19
	Are there Age Differences in Death Anxiety?	20
	Here Come the Boomers	20
	Is Death Anxiety Related to Mental Health and Illness?	21
	Does Religious Belief Lower or Raise Death Anxiety?	21
	Situational Death Anxiety	22
	Theoretical Perspectives on Death Anxiety	23
	Early Psychoanalytic Theory	23
	The Existential Challenge	24
	Edge Theory	25
	Accepting and Denying Death	26
	Is it Really Denial?	26
	The Interpersonal Side of Acceptance and Denial	28
	Anxiety, Denial, and Acceptance: How should We Respond?	29
	In the Shade of the Jambu Tree	30
	Summary	30
	References	31
	Glossary	32
2	What is Death?	35
	Ideas About the Nature and Meaning of Death	36
	Death as Observed, Proclaimed, and Imagined	38
	Death as Symbolic Construction	40
	Biomedical Approaches to the Definition of Death	41
	Traditional Determination of Death	41
	Ways of being Dead	43
	Brain Death and the Harvard Criteria	43
	The Harvard Criteria	45
	The Current Scene	45
	Event versus State	46
	What does Death Mean?	46
	Interpretations of the Death State	47
	Enfeebled Life	47
	Continuation	47
	Perpetual Development	47
	Waiting	48
	Cycling and Recycling	49
	Nothing	50
	Virtual, Therefore not Death	50
	Implications of the Ways in Which We Interpret Death	51
	Conditions that Resemble Death	52
	Inorganic and Unresponsive	52
	Sleep and Altered States of Consciousness	52
	Beings Who Resemble or Represent Death	53
	Death as a Person	55
	How We Personify Death: The First Study	55
	The Follow-Up Study	57
	Conditions that Death Resembles	58
	Social Death	58
	Phenomenological Death	59
	The Undead	60
	The Fertile Dead	60
	From Beast to Dark Lover	60
	Bringing the Vampire Down to Earth	61
	Death as an Agent of Personal, Political, and Social Change	63
	The Great Leveler	63
	The Great Validator	64
	Death Unites/Separates	64
	The Ultimate Problem or the Ultimate Solution?	65
	The Ultimate Meaningless Event	66
	Summary	67
	References	67
	Glossary	69
3	The Death System	71
	A World without Death	75
	General Consequences	76
	Personal Consequences	76
	Basic Characteristics of the Death System	77
	Components of the Death System	78
	People	78
	Places	79
	Times	79
	Objects	81
	Symbols	81
	Functions of the Death System	82
	Warnings and Predictions	82
	Preventing Death	82
	Medical Apartheid	83
	Caring for the Dying	84
	Disposing of the Dead	84
	Social Consolidation After Death	86
	Making Sense of Death	87
	Killing	89
	Sacrifice: Killing for Life	89
	War as a Function of Society	90
	A Deadly Species	90
	Capital Punishment	92
	Supreme Court Decisions	92
	Tsunami, Cyclone, Earthquake, and Hurricane Katrina—Challenges to the Death System	93
	Tsunami: A Stealth Wave and its Impact	94
	Hurricanes Katrina and Rita	95
	The Katrina Timeline	96
	Hurricane Katrina and the Death System	97
	How Our Death System has been Changing—And the “Deathniks” Who are Making a Difference	98
	Changing Ways of Life, Changing Ways of Death	98
	The Beginnings of Death Education, Research, and Counseling	99
	Causes of Death: Yesterday, Today, and Tomorrow	100
	Basic Terms and Concepts	101
	Leading Causes of Death in the United States Today	102
	What will be the Cause of My Death?	103
	Causes of Death in the Future?	103
	Summary	104
	References	105
	Glossary	106
4	Dying	109
	The Moment of Death: Is it Vanishing?	110
	The Slipping Away	111
	What is Dying, and When does it Begin?	114
	Individual and Interpersonal Responses	114
	Onset of the Dying Process: Alternative Perspectives	116
	Trajectories of Dying: From Beginning to End	120
	Certainty and Time	120
	The Lingering Trajectory	121
	The Expected Quick Trajectory	122
	The Unexpected Quick Trajectory	123
	Life-or-Death Emergencies	124
	Guarded Feelings, Subtle Communications	125
	Difficulties in Communication	125
	Doctor-Patient Communication: The SUPPORT Study	126
	Improving Communication	127
	Individuality and Universality in the Experience of Dying	130
	Factors that Influence the Experience of Dying	130
	Theoretical Models of the Dying Process	133
	Do We Die in Stages?	133
	A Developmental Coping Model of the Dying Process	136
	The Dying Person’s Own Reality as the Model	137
	A Multiple Perspective Approach	137
	Your Deathbed Scene	140
	Improving End-of-Life Care	140
	Summary	141
	References	142
	Glossary	144
5	Hospice and Palliative Care	147
	Hospice: A New Flowering from Ancient Roots	148
	Standards of Care for the Terminally Ill	151
	Hidden or Implicit Standards of Care	152
	Proposed Standards Recommended by the International Task Force	152
	The Hospice in Action	154
	Mother’s Last Moments: A Daughter’s Experience	154
	Dying from Two Worlds	155
	Adult Respite Care	156
	Hospice-Inspired Care for Children	157
	Hospice Care for People with AIDS	158
	Hospice Care on the International Scene	158
	Relief of Pain and Suffering	159
	Other Symptoms and Problems	161
	The Last Three Days of Life: From Patients’ Perspective	162
	Your Deathbed Scene, Revisited	163
	Hospice Access, Decision Making, and Challenges	163
	Choosing the Hospice Option	163
	Unequal Access to Hospice Care	164
	Patient Care Issues	165
	Dame Cicely Saunder’s Reflections on Hospice	167
	Summary	170
	References	170
	Glossary	172
6	End-of-Life Issues and Decisions	175
	From Description to Decision Making	176
	Who should Participate in End-of-Life Decisions?	176
	The Living will and its Impact	177
	Right-to-Die Decisions that We can Make	179
	From Living will to Patient Self- Determination Act	179
	College Students’ Attitudes Toward End-of-Life Issues	180
	Advance Medical Directives: What should We Do?	181
	The Combined Advance Directive	182
	With and Without an Advance Directive	183
	A Right not to Die? The Cryonics Alternative	184
	Historical Background	185
	Rationale and Method	185
	Heads of Stone: A Radical New Development	186
	More Questions	186
	Organ Donation	187
	Successful Organ Transplantation	188
	Competition, Tension, Controversy	189
	Becoming a Donor	189
	Funeral-Related Decisions	190
	A Perspective on End-of-Life Decisions	190
	Summary	192
	References	193
	Glossary	194
7	Suicide	197
	What do the Statistics Tell Us?	200
	Suicide Patterns in the United States	201
	Basic Facts	201
	What About Suicide Attempts?	202
	The Human Side	203
	Four Problem Areas	203
	Youth Suicide	203
	Do Children Commit Suicide?	207
	Suicide Among Elderly Persons	208
	The Lethality of Suicide Attempts in the Later Adult Years	209
	Preventing Suicide in the Later Adult Years	210
	Baby Boomers at Risk?	210
	Suicide Among Ethnic and Racial Minorities	211
	Native Americans	211
	African Americans	212
	Military Suicide	212
	High-Risk Situations for Suicide	214
	Gender and Suicide	215
	Balancing Individual and Cultural Influences on Suicide	215
	Some Cultural Meanings of Suicide	216
	Suicide as Sinful	216
	Suicide as Criminal	211
	Suicide as Weakness or Madness	217
	Suicide as “The Great Death”	217
	Suicide as a Rational Alternative	218
	A Powerful Sociological Theory of Suicide	218
	The Importance of Social Integration	219
	Four Type S of Suicide	219
	Some Individual Meanings of Suicide	220
	Suicide for Reunion	220
	Suicide for Rest and Refuge	220
	Suicide for Revenge	221
	Suicide as the Penalty for Failure	222
	Suicide as a Mistake	222
	A Psychoanalytical Approach to Suicide	224
	The Descent Toward Suicide	224
	Facts and Myths About Suicide	225
	Suicide Prevention	226
	Individual Guidelines to Suicide Prevention	226
	Systematic Approaches to Suicide Prevention	227
	Three Emerging Challenges	228
	Are Suicide Terrorists Suicidal?	229
	Summary	230
	References	230
	Glossary	233
8	Violent Death: Murder, Terrorism, Genocide, Disaster, and Accident	235
	Murder	238
	Murder: The Statistical Picture	238
	Patterns of Murder in the United States	239
	Young Men with Guns	242
	School Shootings	243
	Mass and Serial Killers: Who are They and Why do They do It?	244
	Political Murder: Assassination in the United States	246
	Terrorism	248
	Terrorism in History	248
	Twentieth-Century Terrorism and Genocide	250
	9/11/01 and its Consequences	255
	The Day of the Attacks	255
	Immediate Response to the Loss and Trauma	256
	The Mood Changes	257
	Is 9/11 Still Happening?	258
	Does Killing Beget Killing?	260
	Accident and Disaster	261
	Accidents	261
	Laws of Accident Causation?	264
	Natural Disasters	264
	Summary	265
	References	266
	Glossary	268
9	Euthanasia, Assisted Death, Abortion, and the Right to Die	271
	“I Swear by Apollo the Physician”: What Happened to the Hippocratic Oath?	274
	Key Terms and Concepts	275
	Nazi “Euthanasia”	277
	The Black Stork	277
	The Ventilator and the Slippery Slope	279
	Our Changing Attitudes Toward a Right to Die	280
	The Right-to-Die Dilemma: Case Examples	281
	The Ethics of Withdrawing Treatment: The Landmark Quinlan Case	281
	“It’s Over, Debbie”: Compassion or Murder?	282
	An Arrow through the Physician’s Armor	286
	A Supreme Court Ruling: The Nancy Cruzan Case	286
	Terri Schiavo: Who Decides?	288
	The Ordeal Begins	288
	Comments I	288
	The Public Controversy	289
	Comments II	291
	Dr. Kevorkian and the Assisted-Suicide Movement	292
	Assisted Death in the Kevorkian Manner	292
	Kevorkian’s Agenda	293
	Kevorkian’s Method	293
	Evaluating Kevorkian’s Approach	293
	The Netherlands: A Social Experiment Watched Closely by the World	296
	Australia: Yes, and Then No	298
	Assisted Death in the United States	298
	The Oregon Death with Dignity Act	299
	Induced Abortion	301
	Basic Facts About Induced Abortion	301
	Difficult Issues and Questions	302
	Summary	303
	References	304
	Glossary	306
10	Death in the World of Childhood	309
	Respecting the Child’s Concern and Curiosity	310
	Adult Assumptions About Children and Death	312
	Children do Think About Death	313
	Early Experiences with Death in Childhood	313
	Death in the Songs and Games of Childhood	315
	Research and Clinical Evidence	316
	Research Case Histories	318
	Reflections and Questions	322
	Concepts and Fears: Developing through Experience	324
	“Auntie Death’s” Pioneering Study	324
	Stage 1	324
	Stage 2	325
	Stage 3	325
	What has been Learned Since “Auntie Death”?	325
	Does Anxiety Influence Children’s Thoughts About Death?	327
	Cultural Influences on Children’s Concepts of Death	328
	Do Imaginary Friends Die?	329
	How do Children Cope with Bereavement?	333
	A Death in the Family: Effects on the Child	333
	Posttraumatic Stress, Disorder (PTSD) Following a Violent Death	334
	Long-Term Effects of Childhood Bereavement	335
	Helping Children Cope with Bereavement	336
	The Dying Child	338
	Care of the Dying Child	340
	Siblings of the Dying Child	341
	The Stress of Working with Dying Children	342
	Sharing the Child’s Death Concerns: A Few Guidelines	343
	The “Right” to Decide: Should the Child’s Voice be Heard?	344
	Summary	345
	References	346
	Glossary	348
11	Bereavement, Grief, and Mourning	351
	Some Responses to Loss	352
	Defining Our Terms: Bereavement, Grief, Mourning	353
	Bereavement: An Objective Fact	353
	Grief: A Painful Response	354
	Mourning: A Signal of Distress	356
	What Kind of Grief?	361
	Normal and Complicated Grief	361
	Anticipatory Grief	362
	Resolved and Unresolved Grief	363
	Hidden and Disenfranchised Grief	363
	Theories of Grief	364
	The Grief-Work Theory	364
	From Grief-Work to Attachment	365
	Other Theoretical Approaches to Understanding Grief	367
	How do People Recover from Grief?	369
	When a Husband or Wife Dies	369
	The Family that has Lost a Child	375
	Bereavement in Later Life	377
	Sorrow Upon Sorrow, Loss Upon Loss	378
	Are Bereaved People at Higher Risk for Death?	379
	Differential Mortality Risk: The Statistical Pattern	379
	Who is Most at Risk?	379
	What are the Leading Causes of Death Among the Bereaved?	379
	How Well do We Support the Bereaved?	380
	American Society’s Discomfort with Grief and Mourning	380
	Meaningful Help for Bereaved People	382
	Widow-to-Widow: The Phyllis Silverman Interview	382
	Helpful and Unhelpful Responses to the Bereaved Person	383
	Professional Help: When is it Needed?	384
	Widows in Third World Nations	385
	On the Future of Grieving and Mourning	386
	Summary	386
	References	387
	Glossary	390
12	The Funeral Process	393
	A Sampler of Responses to the Dead	394
	Respect and Remembering	394
	The Bones Start Screaming	396
	“These People Got Nobody”	396
	Postmortem Abuse	397
	“Laid Out”	397
	What do Funerals Mean to Us?	398
	From Dead Body to Living Memory: A Process Approach	400
	Common Elements of the Funeral Process	400
	The Funeral Service	407
	Memorializing the Deceased	408
	Getting on with Life	408
	Making Death “Legal”	408
	Establishing the Facts of Death	409
	What does the Funeral Process Accomplish?	409
	When Great People Die	410
	Balancing the Claims of the Living and the Dead	414
	In the Shadow of Mount Olympus	414
	Kotas and Orthodox Jews	416
	Memories of Our People: Cemeteries in the United States	416
	The Neighborhood Cemetery	417
	Ethnic Cemeteries in the United States	418
	The Place of the Dead in Society: Yesterday and Today	420
	When are the Dead Important to the Living?	420
	American Memory and the Casualties of War and Terrorism	422
	World War I Memorial: Still Missing in Action	423
	Who “Owns” Human Remains?	424
	“You Were the Best Dog Ever”: The Pet Cemetery	425
	The Funeral Director’s Perspective	426
	Improving the Funeral Process	428
	Alternative Funerals	429
	The Memorial Society Option	429
	Green Funerals	429
	Flushing the Dead: Alkaline Hydrolysis	430
	Virtual Memorials	431
	Spontaneous Memorialization in Response to Violent Death	431
	Integrity and Abuse in the Funeral and Memorial Process	432
	Summary	433
	References	434
	Glossary	436
13	Do We Survive Death?	439
	Concept of Survival in Historical Perspective	441
	Key Points	445
	The Journey of the Dead	446
	Heavens and Hells	447
	The Desert Religions and their One God	447
	Jewish Survival Belief in the Ancient World	448
	Heaven and Hell for Christians	448
	Islamic Paradise and Jahannam	449
	What Other People Believe Today	450
	Baby Boomers Scan the Afterlife	450
	United States: A Nation of Believers?	451
	A Southern Perspective	451
	What do Belief-Oriented People Believe About the Afterlife?	452
	The Afterlife: A Mirror of Society?	452
	Can Survival be Proved?	453
	Ghosts	453
	The Ghost Dance: A Peaceful Vision Becomes a Tragedy	455
	Deathbed Escorts: Safe Conduct to the Other World	456
	Reincarnation	457
	When Spiritism was in Flower	458
	A Frustrating Quest	460
	An Apple on a String	462
	Near-Death Experiences: Evidence for Survival?	463
	Evidence Favoring the NDE as Proof of Survival	463
	Biomedical Attempts to Verify NDE Phenomena	463
	Eliminating Other Explanations	465
	The Case Against the NDE as Proof of Survival	465
	Mystical, Depersonalization, and Hyperalertness Responses to Crisis	466
	When do People Not have NDEs? An Alternative Explanation	467
	NDEs as Exercises in Religious Imagination?	467
	The G-Loc Problem	468
	What has been Learned from NDERs?	468
	Should We Survive Death?	469
	But What Kind of Survival?	470
	Assisted and Symbolic Survival	471
	Symbolic Immortality	472
	Assisted Immortality	473
	The Suicide-Survival Connection	474
	Summary	475
	References	476
	Glossary	478
14	How can We Help?	481
	“Compassionate Fatigue”: Burnout and the Healthcare Provider	483
	Caregivers in Death-Salient Situations	485
	Staff Burnout: What Effects on Patients?	456
	How can We Protect Ourselves from Burnout?	486
	Whose Problem? Whose Need?	487
	Death Educators and Counselors: The “Border Patrol”	488
	Death Education in Historical Perspective	488
	From Ancient Times	488
	The Medieval Heritage	489
	Death Education and Counseling: The Current Scene	490
	SimMan: An Interview with Beatrice Kastenbaum, MSN	493
	Counseling and the Counselors	495
	Characteristics of Professionals in the Death System	495
	Counseling and Psychotherapy	496
	How We All can Help	496
	Summary	498
	References	498
	Glossary	500
15	Good Life, Good Death?	503
	Three Paths to Death	506
	A Father Dies: A Mission Begins	508
	A Shift in the Meaning of Life and Death?	509
	The Golden Rule Revisited	511
	Are We Live or on Tape? the Life-and-Death Challenges of Virtual Reality	513
	Utopia: A Better Death in a Better Place?	515
	Death in Utopia	516
	A Better Death in a Better Place?	517
	“The Good Death”: Fantasy or Reality?	518
	Extinction: Death of Life or Death of Death?	522
	St. Paul’s Cathedral, 1623	522
	The Death of Species	524
	From Good Life to Good Death: A Personal Statement	525
	Summary	526
	References	527
	Glossary	529
	Index	530