The Encyclopedia of Death and Dying

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					  THE ENCYCLOPEDIA OF

DEATH AND DYING
       THE ENCYCLOPEDIA OF


DEATH AND DYING

            Dana K. Cassell
   Robert C. Salinas, M.D., CAQ(G)
Peter A. S. Winn, M.D., CMD, CAQ(G)
                            The Encyclopedia of Death and Dying

                                 Copyright © 2005 by Dana K. Cassell

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                       Library of Congress Cataloging-in-Publication Data

                                         Salinas, Robert C.
          The encyclopedia of death and dying / Robert C. Salinas and Peter A. S. Winn.
                                              p. ; cm.
                                Includes bibliographical references.
                              ISBN 0-8160-5376-6 (hc : alk. paper)
1. Death—Encyclopedias. 2. Thanatology—Encyclopedias. [DNLM: 1. Death—Encyclopedias—English.
             2. Thanatology—Encyclopedias—English.] I. Winn, Peter A. S. II. Title.
                                          HQ1073.S25 2005
                               306.9’03—dc22           2003027478


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               CONTENTS
Foreword                   vii
Preface                    ix
Acknowledgments           xiii
Introduction               xv
Entries A–Z                 1
Appendixes                279
Bibliography              335
Index                     345
                                      FOREWORD
                                                                often term “comfort care” and/or “palliative care.”
I  ntertwined into the ABC’s of The Encyclopedia of
   Death and Dying are several challenges to us all.
First is the challenge to better understand the expe-
                                                                However “comfort care” does not necessarily mean
                                                                “no care.” It can entail aggressive care that addresses
rience of death and dying. This experience is a kalei-          and treats pain and a myriad of other non-pain and
doscope of many factors—the dying person’s past                 distressful symptoms that can lead to overwhelming
life experiences; his or her legacy (or lack thereof)           suffering and discomfort. Only when we alleviate
after death; the emotional, social, religious, spiri-           the dying person’s physical, emotional, social, spir-
tual, and family contexts of death and dying—all                itual, and existential suffering can a peaceful death
filtered through the dying person’s beliefs and cul-             truly occur, one that suffuses contentment and a
tural and ethnic diversity. Diverse communities,                readiness to finally let go of life’s last threads.
societies, and countries are challenged to grapple                 The seminal works and writings of several pio-
with the unique issues related to death and dying.              neers in end-of-life care have profoundly influenced
    From a health care perspective, we are challenged           many of us who have cared for the dying. These
to better alleviate suffering and increase comfort as           include Elisabeth Kübler-Ross (On Death and Dying,
people travel through the last phase of their lives.            1969, and her many subsequent publications), Mag-
We need to better understand the dying person’s                 gie Callanan and Patricia Kelley (Final Gifts, 1992),
fear of death and loss, his questions about dying, as           Sherwin Nuland (How We Die, 1993), Ira Byock
well as her desires and unfulfilled needs. We also               (Dying Well, 1997), Daniel Tobin (Peaceful Dying,
need to respect people’s individual rights to dignity,          1999), and Joanne Lynn and Joan Harrold (Hand-
autonomy in making decisions, beneficence (doing                 book for Mortals, 1999). All these classic writings form
good), non-maleficence (do no harm), confidential-                a cornerstone to better understanding of death and
ity (right to privacy), and trust throughout the last           dying. The Encyclopedia of Death and Dying is another
months of their lives. This is a time to recognize and          seminal work that is both thoughtful and helps ful-
facilitate the dying person and his family’s need to            fill our yearning for knowledge on death and dying.
reconcile past and present personal, spiritual, and             Personally this text has encouraged me to return to
moral relationships.                                            the pioneers’ writings mentioned above, all in a
    In Final Gifts, Maggie Callanan and Patricia Kelley         search to better understand our culture of death and
have challenged family and health care profession-              dying.
als to become more sensitive to the messages, teach-               All dying persons and their families must be
ings, and needs of the dying and the dying person’s             assured access to a philosophy of care and treatment
personal experience so that peaceful dying can be               options that provide comfort, peaceful dying, and
achieved. To do so requires a philosophy of care we             the dying person living each day to the fullest until




                                                          vii
viii The Encyclopedia of Death and Dying

he or she dies. It is my hope that this encyclopedia    better care for our loved ones in this and future
will help us all to better understand the care and      decades. The Encyclopedia of Death and Dying should
end-of-life issues related to death and dying in the    prove to be a useful resource to both families and
past and present, which in turn will enable us all to   health care professionals.

                                                                —Peter Winn, M.D., CMD, Palliative Care
                                                              Committee, University of Oklahoma Health
                                                            Science Center Faculty, Department of Family
                                                               and Preventive Medicine, Adjunct Faculty,
                                                                D. W. Reynolds Department of Geriatrics,
                                                                      Diplomat of the American Board of
                                                                         Hospice and Palliative Medicine
                                             PREFACE
D     uring the past year, I have been reviewing the
      contents of this unique book, The Encyclopedia of
Death and Dying, and now as I am writing this pref-
                                                                 these deeply embedded experiences. They have
                                                                 taught me that despite the marvel of modern potions
                                                                 and technology used to control symptoms, treating
ace, I would like to take this opportunity to reflect             the spirit is just as important and often central to
and share some thoughts on such an important mat-                good doctoring. For when medications could not
ter. Let me begin by stating that I am not nor do I              bring optimal relief of suffering, my patients have
consider myself an expert in the field of end-of-life             found comfort in readings from the Holy Bible. (In
care or palliative and hospice medicine. Simply, I am            addition to the medications and medical instruments
an academic-based family physician whose practice                that are found in my doctor’s bag, a copy of the Holy
involves providing medical care for those people                 Bible remains a valuable necessity.)
who are dying. My responsibilities also include                      Death and dying have been succinctly depicted in
teaching medical learners about the potentials of                literature, in art, and in song for hundreds of years.
doing great things for patients and their families dur-          I am reminded of one particular story that has with-
ing a very challenging period in their lives. In addi-           stood the test of time. In the novella The Death of
tion to my other academic duties, I write and share              Ivan Ilyitch, written by Leo Tolstoy, the reader wit-
narratives about death and dying. Much of what I                 nesses the personal struggles and ultimate convic-
write is based on an exploration of current medical              tions that Ivan Ilyitch must bare as he reaches the
theory and well-done studies that are intertwined                final moment of life. Many of the themes that Tol-
with my personal experiences in providing end-of-                stoy wrote about more than a hundred years ago
life care for patients.                                          remain central to care of the dying patient today.
    My patients and their families grant me a special            This story reflects the humanism germane to the act
privilege when I am asked to assist with end-of-life             of dying. As readers, we experience the emotional
care. When I am called to the bedside of a dying                 entanglements involving death that affect us all as
patient, I am inspired by the emotional exchange                 humans. We hurt. We fear. We grieve. We care. And
that we share as we recollect and celebrate the                  at times, we don’t understand until the end as we
patient’s personal meaning in life. These stories                blindly seek spiritual salvation. We become intro-
abound for there have been many instances when,                  spective as we approach the abyss of death and an
late at night with medical bag in tow, these special             apparent dark and gloomy fate. These are all com-
moments of visiting the infirm have taught me about               mon characteristics of the human condition.
the virtues of living and dying. Huddling in the liv-                What has changed over the past hundred years or
ing room with family members to discuss the                      so is the vernacular used to describe the pure essence
expected fate of their loved ones has also reminded              of the life process called dying. Like Tolstoy, we have
me of my expanded participatory role as a healer                 attempted to describe and add meaning to one of
during my patient’s last moments of life. It is a trusted        life’s most feared events. The meaning of death and
role, and I have remained humbled and grounded by                dying is not distinct to one race or ethnic group but

                                                            ix
x The Encyclopedia of Death and Dying

rather universal, with a multitude of individual char-    potentially harming effects that good intentions may
acteristics that are expressed in various customs and     bring. It remains inherent upon us as physicians to
beliefs. Cultural constructs regarding illness and        continue to communicate with our patients and
death and dying are required to be accepted as part       establish a platform for discourse on end-of-life care.
of any exchange between patient and provider. Sen-           The communication of death and dying has
sitivity and understanding is paramount to good           evolved through a multitude of delivery conduits
end-of-life care. For example, why is it that when a      with the purpose of reaching people through various
child of Hindu religion dies, it is important that the    means. The media has certainly played an important
child be close to the ground? Included throughout         role and is also partially responsible for bringing end-
this book are global perspectives that provide insights   of-life care to centerstage. Big screen movies and
into various cultural traditions regarding death and      prime-time television programs have successfully
dying. These traditions and ways of life will provide     communicated topics of end-of-life care through film.
a platform for discussions among patients, family         One can also acknowledge the growth and develop-
members, and their physicians.                            ment of our culture as motion pictures and television
    Much credit can be given to the people who            have captured snapshots of our society. Productions
choose to make end-of-life care a lifelong study. These   from Hollywood archive our post-modern society’s
are the people who collectively have made substan-        interpretation of dealing with the final acts of death
tial contributions to the field of sociology, anthro-      and dying. Such productions that come to mind
pology, medical ethics, hospice care, and palliative      include the award-winning movies Terms of Endear-
medicine. Their attempts to bring clarity to what         ment and Philadelphia, and the television program ER.
seems to be an often nebulous and cumbersome              Each media source from a particular decade relates a
ordeal, deserve continued support and recognition.        different perspective of end-of-life care.
    Some of these professionals bare their own emo-          The information gathered from the SUPPORT
tions through personal accounts of working with           studies are landmark educational platforms that will
dying patients. These authors provide narrative tales     serve to guide us, as we look for ways in which to
from their patients’ files, and these narratives          improve care for the dying. These studies remain
describe the unfortunate human tragedies that cut         our beacon of light and as a society, it is incumbent
short a wonderful life and the suffering inflicted by      upon us to understand the significance of what these
this circumstance. Such stories remind us of the          SUPPORT authors assert. The tasks are multitude but
inevitable and of our own mortality. As humans,           yet achievable. For example, caring for people who
we feel sorrow, and as physicians, we struggle to         are dying should be a standard part of any health
acknowledge our limitations as defeat looms. At           professional school’s curriculum. However, informa-
times, we hobble away a wounded healer; for what          tion on end-of-life care is often not found in the text-
was to be is not.                                         books that these students read. Major medical
    Other authors describe the perspective of the         textbooks often devote little space to this subject, and
patient, who is often caught in the middle, often the     didactics are often restricted to only primary care spe-
victim of the ill-intended decisions of over-zealous      cialties. However, because of the unremitting efforts
doctors attempting to employ the wizardry of mod-         of the authors involved with the SUPPORT studies,
ern medicine and satisfy society’s norms. In Brian        academic medical education has initiated an infusion
Clark’s short play, Who’s Life Is It Anyway?, we are      of more didactic training and patient care experience.
tragically reminded that patients ultimately will            As we constantly balance the use of technological
decide if they wish to live or to die. Physicians and     medical breakthroughs for keeping people and
health professionals are delegated to being cast mem-     patient autonomy, new discussions emerge. The
bers and are seen as clerks who provide the means for     curative model engages the caring model and we
the sustenance of life. Patient autonomy and freedom      must learn to understand our own views and opin-
of choice is pitted against our moral values as a soci-   ions as we listen intently to the needs of our patients.
ety and obligation to stand firm and defend our oath.      Our ability to endure these realities must include an
This short masterpiece reminds us of the duality and      approach that is centered on patient and family. The
                                                                                                      Preface xi

goals of good end-of-life care should be focused on       cation attainment, and cultural beliefs. These barriers
relieving pain and suffering. I am poignantly             can inadvertently promote a profound assumption
reminded of an elderly couple that jumped to their        of singularity in regards to the delivery of medical ser-
death from atop a high-rise apartment building            vices to an individual, irrespective of ethnic or cul-
because the husband was tired of living with ill-fated    tural backgrounds. Understanding the special needs
lungs that prevented him from breathing well. Was         of a diverse population will help prevent a widening
his end-of-life care good, I wonder?                      of the gap in end-of-life care services.
    The balance of longevity and a life well spent will       Despite the tremendous progress with techno-
certainly provide a discourse for anyone as we move       logical breakthroughs, people continue to experi-
from a curing mode of treatment to a caring mode of       ence the illness and disease that call for a suspension
treatment. Tensions that exist may be eased and a         of life. Throughout the world, thousands die daily
patient’s final wishes may be honored when a cure is       because of modern medicine’s inability to control
futile. We know that despite the majority of people       disease progression. Illnesses such as cancer and
wanting to die at home, most actually die in a place      heart disease continue to be the leading causes of
other than home, such as a nursing home or hospi-         death in the world. Each day people must deal with
tal. I am too often reminded of stories where I am        the realities of life; we are born and we die.
told “Dad didn’t want to be resuscitated and be put           This encyclopedia is rich in information about
on a ventilator but the hospital was not aware of this    everyone’s final act and the way society interprets
so he died in the Intensive Care Unit (ICU) a week        this as a means of understanding death and dying. It
later.” Thus, we must continue to explore and imple-      is reflective of the close relationship among medi-
ment strategies that will allow patient and physician     cine, religion, and social norms that is woven into
to share communication on end-of-life care.               the fabric of our society. It provides clarity and
    A compassionate and caring approach to the            understanding with the hope of illuminating world
patient has been central to the idea of palliative and    concepts and ideas that may reduce a centricity that
hospice care. With a highly diverse society, an under-    all too often comes to affect us. Thus this encyclope-
standing of cultural perspectives and values also         dia will serve not only the public but also those
becomes imperative in the commitment to patient           health care professionals who seek to improve their
care. Cultural norms on end-of-life care that are         knowledge base to provide better end-of-life care.
described in this book are of value to any physician      Without doubt, the contents of this book will help
in neutralizing ethnocentricity and ignorance. Let’s      fortify and expand the reader’s fund of knowledge. If
face it: America has a population that continues to       these are the goals, then I suspect that this book will
demonstrate wide cultural diversity. Along with this      be of value and serve to enrich the lives of the peo-
are the cultural norms that may defy one’s own per-       ple that we serve. It should be considered a primer
spective on end-of-life care. Certainly some of the       for any discourse on end-of-life care and I hope that
goals that we hope to attain in end-of-life care tra-     this foreword sets the tone for a meaningful and val-
verse the kaleidoscope of America. Understanding          ued experience for the reader. I am grateful to all my
the special needs of a diverse population will help       colleagues who steadfastly continue to make contri-
prevent a widening of the gap in end-of-life care ser-    butions to this field. And to my patients and their
vices. The ability to render effective medical services   families, I am indebted for the special relationship
to people from diverse cultural backgrounds remains       that we have forged during life’s final steps.
a priority for our health care system. Research con-
tinues to demonstrate that ethnic minorities often             —Robert C. Salinas, M.D., Assistant Professor,
experience barriers when accessing hospice and end-          Department of Family and Preventive Medicine,
of-life care services when compared to Caucasians.             College of Medicine, University of Oklahoma
Characteristics attributable to existing barriers often            Health Sciences Center Medical Director,
include economic status, language acquisition, edu-                                 Gentiva Health Services
                      ACKNOWLEDGMENTS
S   ubjects like death and dying, which touch every-
    one’s life, encourage input from so many that it
would be impossible to thank everyone who has
                                                               Harwell Sayler, author of Poetry Writing One-on-One
                                                               (Ocean Publishing, 2004), contributed the entry on
                                                               “poetry on death and dying” and also suggested
contributed to the value of this encyclopedia, either          many of the topic listings used in this book. Another
directly or indirectly through their own life experi-          contributor of suggested topics was Vicki DeLalla.
ences. But several people have been especially help-              We would also like to express appreciation to the
ful. Christine Adamec, herself author of several               staffs of several organizations, who were especially
encyclopedias in the Facts On File Library of Health           generous in allowing the use of their material and
and Living series, has also written on end-of-life             information—Project Grace in Clearwater, Florida; the
issues and was kind enough to send along a large               National Safety Council in Itasca, Illinois; and Jenkins
box of resource material that was very helpful. Mary           Funeral Home in Colebrook, New Hampshire.




                                                        xiii
                               INTRODUCTION
                                                               “Many people use the words frightening, painful, or
D    eath has been an absolute since the beginning
     of life; but rather than such familiarity yielding
definitive answers to questions about death’s mean-
                                                               horrible when they think of death. But at the same
                                                               time others find peace, release and triumph more
ing and handling, death’s constant presence has                appropriate.”
instead intrigued and frightened man throughout                   From its contradictions to its rich cultural and
history. Every culture, every religion has endeav-             social history, all aspects of death have been studied
ored to explain its meaning. Although biological               by anthropologists, sociologists, philosophers, psy-
death is universal, the attitude toward death and              chologists, and biologists in an attempt to better
the beliefs connected with death have changed over             understand its meanings.
time. Rituals to ease the transition of a death for
both the departed and the survivors have spanned
the ages, constantly evolving, but with some cus-              Prehistoric Death Practices
toms periodically reappearing. As we follow the ages           Largely due to lack of a written language, little is
and histories of man, it is remarkable how recog-              known about prehistoric man’s attitudes about
nizable earlier customs are in today’s traditions,             death, but early Stone Age (Lower Paleolithic
practices, and beliefs.                                        period) scattered bone fragments have suggested to
    Death has also had its share of paradoxes. In The          archaeologists that the dead were simply abandoned
Courage to Laugh: Humor, Hope, and Healing in the Face         and left behind as groups continued on their migra-
of Death and Dying, Allen Klein notes that today’s             tory way, following the animals and seasons. It is
American culture has chosen to emphasize the                   not known precisely when the custom of burying
“loss” a death entails and the difference between life         the dead began, but the Neanderthals (Middle Pale-
and death. “In ancient Eastern cultures, life and              olithic period), in contrast to these earlier hominids,
death are not classified as opposing forces but sim-            apparently buried many of their dead. Also
ply as aspects of existence.” Another paradox Klein            unknown is whether the earliest burials were
mentions is the fact that we are both repelled and             intended to maintain communication (as in a cult of
intrigued by death. “We ship our deceased off to a             the dead) or to guard against the demonic power of
mortuary for rituals that once were performed at               unburied dead left free to wander. Several Nean-
home, yet we are constantly bringing reminders of              derthal burial sites contain what appear to have
death into our house through grim media headlines              been valuables or “grave goods,” indicating an abil-
and gruesome television shows.” Such fascination               ity to think about symbolism and perhaps even a
with death and the macabre has whetted our                     belief in an afterlife. For example, Lewis Aiken
appetite for films about ending lives in violent ways           writes in Dying, Death and Bereavement, “The grave of
at the same time that we express horror at genocide.           a Neanderthal man who lived about 70,000 years
But on a more personal level, there is also a paradox          ago in what is now southwestern France also con-
in people’s descriptions of death. Klein explains,             tained a leg of bison with the flesh still attached. The
                                                          xv
xvi The Encyclopedia of Death and Dying

implication of this finding seems to be that the leg          with it continued to be fairly prevalent. In some
was buried to provide meat for the deceased in the           cases the arms were folded over the heart and the
next life.” The presence of pots in the earliest known       lower limbs flexed. “On the whole,” Warden says, “it
graves also indicates that the bodily needs of the           appears that late Paleolithic man thought of life after
deceased were provided for.                                  death as a continuance of the present mode of exis-
    There seems to be general agreement that ritual-         tence. However, the votive offerings may have been
ized burial began with the Neanderthals. Other               intended for use merely during the journey to the
examples of this period, described by Constance              land beyond.”
Jones in R.I.P., include remains surrounded by the               Beginning around 10,000 B.C.E. in the Middle
pollen of flowers—perhaps an attempt to “cure”               East, the Neolithic (New Stone Age) people were
death, or perhaps simply the earliest use of floral           the forerunners of the Europeans of ancient history,
arrangements to decorate a grave. Neanderthal                bringing with them later to Europe the culture of a
graves have also included weapons and flints and              more settled, agrarian life and conquering the
food—possibly as protection from predators or evil           nomadic Cro-Magnon race. The highest architec-
spirits, or perhaps as useful items for the next life.       tural skill of Neolithic man was expressed in the
Discovery of Neanderthals buried along with sys-             building of various sorts of crude stone tombs, or
tematic arrangement of cave bear bones in France             dolmens, for family or community use, before the
and the Swiss Alps has suggested the possibility of          age of individual graves arrived. These tombs ranged
their connecting death to hibernation—perhaps “an            from a simple room to those having several cham-
attempt to transfer the power and mystery of hiber-          bers and a passageway. These tombs were protected
nation.” Jones also writes, “Some (Neanderthal)              by a mound of stones and earth, known as a tumu-
bodies are found facing east, as if they were posi-          lus or barrow, which was sometimes surrounded by
tioned so that their spirits might awaken to some            another row of stones. Because Neolithic man’s
future dawn.” The painting of the dead prior to bur-         rudimentary artistry left few clues as to his social
ial is a further indication that some kind of primitive      and religious life, archaeologists and anthropolo-
religion may have been practiced.                            gists have had to rely on his burial customs for infer-
    The Upper (or more recent) Paleolithic period            ences of his beliefs. Warden explains, “Doubtless he
included Cro-Magnon man, among other fully erect             laid away his dead with elaborate ritual in the dol-
Homo sapiens, who were the first to hunt and fish in           mens which had been so laboriously constructed.”
groups, as well as the first to have belief systems           The group burial tombs were located close by, some-
centering on magic and the supernatural—and,                 times at the mouth of or within the cave where peo-
likely related, the first regular burial practices. Carl J.   ple lived. Superstition, even cults, are believed to
Warden (The Evolution of Human Behavior) writes,             have been the order of the day.
“The artist and magician of the times was doubtless              As the Neolithic races gradually made their way
also the priest and performed the ceremonial rites           across Europe to England, they became known as
associated with the burial of the dead.” The practice        the “long barrow” people, because they built their
of burying offerings with the dead, seen during the          burial chambers, or barrows, long, as differentiated
earlier period, continued and expanded during the            from the round barrows of the later Bronze Age peo-
Upper Paleolithic period. Warden explains, “Not only         ple, whose culture marked the dawn of ancient civi-
food for sustenance, but also richly carved weapons          lization. The numerous changes in burial practices
and implements of the chase for use in the happy             during the Neolithic period in Britain (4000–2500
hunting grounds were now placed with the dead.               B.C.E.) has sparked debate among archaeologists and
Pendants, strings of beads, necklaces, and the like          anthropologists for generations, as they have endeav-
are also commonly found with fossil remains of the           ored to interpret the meaning of these changes.
period.” Although there is no way of knowing                     One of the major changes during this period was
whether or not actual burial ceremonies took place,          a decline in the use of the communal tombs and
it is likely that certain rites were performed. The          the introduction toward the end of the period of a
practices of painting the corpse and of burying paint        single-grave burial that included grave goods. Some
                                                                                          Introduction xvii

authorities attribute the change to the arrival of a    Payne notes that in parts of Madagascar, elaborate
new group of people, the “Beaker folk,” so called       funeral rites still take place involving large numbers
because they included distinctive “waisted” pots        of cattle.
(Beaker ware) in their burials. As roving warriors,         Much of the burial practice of Neolithic man con-
communal burials had little appeal, with solitary       tinued into the Bronze Age in Britain and Europe,
graves more conducive to their vagabond lifestyle.      although new elements also made their appearance.
So their dead were buried alone and in a crouching      The dolmen continued to be used for burial in certain
position, with their knees pulled up close to their     communities, although burial in flat graves occurred
chins. Others have suggested that the move to sin-      in some places. Later on, incineration became usual,
gle graves came about as communities began band-        with the ashes being placed in a pottery urn and
ing together to form chiefdoms, resulting over time     buried in a solitary grave along with grave goods
in a ranking of people as to importance and wealth,     that included pots, jewelry, and weapons.
and the adoption of styles of burial that illustrated       Limited evidence exists of body disposal and
their individual prestige. Still others have argued     afterlife beliefs during the Iron Age because burial of
that communal burials were intended as a means of       the dead was not usual for most Iron Age commu-
pursuing ancestor worship—with the accessibility        nities in Britain or Ireland, according to historians,
of the remains enabling them to be retrieved, han-      although burials become more usual from the 1st
dled, or displayed during the course of ancestral       century B.C.E. onward. J. D. Hill, writing for the
rites. Thus, they suggest, the move to single graves    BBC, notes that in most areas Iron Age graves are
marked a change from ancestor worship to a              either extremely rare or completely absent. It is only
“funeral,” with attention (and gifts) now given to      because of the religious beliefs and rituals of partic-
those who survived—the first instance of “social        ular Iron Age groups—which caused some dead
death.” Noting that during this same time period,       people to be buried in graves, and demanded that
entrances to many of the stone chambers of western      these dead should be clothed and furnished with
Britain began to be deliberately blocked with stone     other objects—that some rare Iron Age artifacts
and earth, making the ancestral bones inaccessible,     have survived at all. These few isolated burial sites
Julian Thomas suggests that the introduction of         have shown funerary styles such as cart burials, cist
single-grave burial was more a societal change, with    cemeteries (burial chamber made from stone or a
people wanting more of a separation between them        hollowed tree), and warrior graves with remains of
and their dead. As personal identity began to           sword and shield. More recent excavation has
emerge more through descent rather than from            shown frequent evidence of a complicated funeral
group affiliation, this realignment of personal iden-    ceremony based on seasonal rites and centered
tity “created an imperative to identify the dead as a   around a “mortuary house” in which the remains
point of origin from which the present descends.        were placed.
The dead had to cease to be part of the present, and        Throughout the Iron Age, it appears, a variety of
had to be relocated both spatially and in the past,     strange burial rituals were carried out, attributed to
placing them in a different kind of relationship with   widely changing religions and no one system of bur-
the living.”                                            ial. As one person working a dig has said, “Some
    Illustrative of the value and symbolism put on      people were buried, some were cremated, others
cattle during this Beaker period, a Beaker grave        had their heads chopped off and put below their
uncovered in central England included the remains       legs and I’ve even seen one body that was nailed to
of 185 skulls and a smaller number of jawbones,         the ground.”
shoulder blades, and pelvic bones of cattle. Other          According to Oxford Archaeology, the largest
parts of the skeletons and other species were con-      independent archaeological practice in England,
spicuously rare or absent. Sebastian Payne writes       chariot burials remain one of the rarest and most
that there can be little doubt that such an assem-      intriguing forms of burial rites known in Britain. Dat-
blage is the result of some kind of ritual associated   ing from roughly 500–100 B.C.E., they are thought to
with the death of the man buried in the barrow.         represent the final rites of elite individuals of the
xviii The Encyclopedia of Death and Dying

middle Iron Age. Typically, archaeologists find a sin-     family vault under the dwelling house was com-
gle burial placed in a large grave with a two-            mon. Others have also described the Mesopotamian
wheeled vehicle. These vehicles are usually referred      funeral service as simple, with elegists and other
to as chariots, although what they were originally        funerary personnel in attendance to conduct the
used for is still not certainly known. The burials are    laments seeking to give full expression to the grief of
often accompanied by other high-status objects,           the bereaved and appease the spirit of the deceased.
including mirrors and swords. Chariot burials, espe-          In excavations of the city-state of Ur, located in
cially intact examples in which the chariot is buried     antiquity at the head of the Persian Gulf, of 660
complete, are considered significant because they          graves dating to the Early Dynastic period (ca.
indicate some form of contact and exchange                2600–2500 B.C.E.), the majority were simple ground
between the Continent and Britain during the mid-         burials in which a single body, wrapped in reed mat-
dle Iron Age.                                             ting or placed in a coffin, rested at the bottom of a
                                                          small rectangular pit. In these burials, the deceased
                                                          was accompanied by a few personal possessions,
Death Practices in                                        such as jewelry or weapons, as well as vessels, pre-
Early Civilizations                                       sumably to hold food and drink. Sixteen burials,
During the early Bronze Age, certain parts of the         however, were distinguished from the others by
world—in areas of the current Near East and Asia—         their wealth. The inhabitants were also accompa-
were witness to the awakening of civilization,            nied in their graves by a number of other individu-
meaning urban life and literacy. Among the more           als. Both the wealth and the “entourage” have led to
well-known “cradles” of civilization were Mesopo-         assumptions that these interments contained the
tamia, between the Tigris and the Euphrates rivers        deceased kings and queens of Early Dynastic Ur.
in present-day Iraq, the Indus River Valley in north-     Authors have noted that in the royal tombs of
western India and Pakistan, and ancient Egypt along       ancient Mesopotamia the courtiers—guards, musi-
the Nile River. Each of these civilizations developed     cians, handmaidens, and grooms—died at their posts
the first cities and can lay claim to the first writing,    in the tomb, having taken a lethal drink of poison.
which historians use as a marker between prehis-              As the last of the great civilizations of antiquity to
tory and the beginning of history. Such writings          be discovered, less is known about the Indus people
have been an aid to gaining knowledge about bur-          and their attitudes about death; in fact, the largest
ial practices, but more importantly insight into atti-    known Indus culture site has yet to be excavated.
tudes about death.                                        Although there were Indus writings, developed
    In Ancient Mesopotamia (Cambridge University          independently of the Mesopotamian and Egyptian
Press, 1999) Susan Pollock notes that burial prac-        writings, these have yet to be deciphered, thus lim-
tices changed from the use of cemeteries and intra-       iting current knowledge. Also, according to histori-
mural interments in the fifth millennium, to the          ans, the nature of the graves themselves has
curious absence of burials for at least a thousand        hindered knowledge. Dr. Gregory L. Possehl of the
years during the fourth millennium, to renewed            University of Pennsylvania, who has excavated
burial in the third, often accompanied by substantial     Indus cities since the 1960s and written several
quantities of grave goods that clearly single out indi-   books on the culture, has explained that the appar-
viduals of status. Whether there actually were no         ently simple Indus burial practices have deprived
burials for a millennium, or whether they simply          archaeologists of what is usually a most revealing
have not yet been discovered has been debated             lode of cultural information. Unlike the elites of
among historians.                                         Egypt and Mesopotamia, the Indus people sent their
    Indeed, Jones writes, the Mesopotamians had a         dead to the afterworld unaccompanied by jewels,
pessimistic view of death and treated it simply—          furniture, and weapons. Previous excavations have
“their architecturally unmemorable graves are cov-        indicated that some people were buried in wooden
ered over with earth, a sharp contrast with Egypt’s       coffins with pottery vessels that may have been
Pyramids.” In later eras in the region, burial in a       filled with food. But having found so few cemeteries,
                                                                                          Introduction xix

archaeologists suspect that burial was not the rule;    vided ample provisions for the afterlife—jewels,
perhaps most bodies were cremated or thrown into        household furnishings, and food. The intricate sys-
rivers. It is interesting to note that where inhuma-    tem of death care was carried out by an elaborate,
tion did occur, there was a common pattern of           extensive division of labor, with “undertakers” and
cemeteries outside the town. At one burial site, sev-   embalming specialists caring for the dead and han-
eral pairs of skeletons were found together in the      dling many of the funeral arrangements. The food
same graves, suggesting some form of suttee, a later    placed in the tombs was presumably replenished
Hindu custom in which the wife ended her life with      periodically by attending priests, such services con-
the death of her husband.                               sidered a continuation of the existence before death.
   In addition to the royal Mesopotamians and pos-      The Book of the Dead preserved magic formulas to be
sibly the Indus people taking live persons to the       used in approaching the underworld. No restrictions
grave with them, Aiken notes that the Scythians, a      were placed on who could have a copy of the Book
nomadic people who lived in southern and eastern        of the Dead to take along with them, but the cost
Europe from 600 B.C.E. to 100 C.E., killed wives and    prevented lower classes from buying it. Most of the
servants to accompany the deceased, a rite also         owners belonged to the social strata of officials and
practiced among the Vikings of northern Europe.         qualified workmen of the royal tombs.
The early Egyptians followed a similar practice, but        The decorated stone coffins (called sarcophagi)
paddle dolls later replaced people in Egyptian tombs.   and tombs of the Egyptians were also used by other
Paddle dolls, shaped from thin strips of board into     ancient cultures, such as the early Greeks, who
small canoe paddles, were placed in the tombs to act    carved their tombs out of rock or buried them in the
as servants and companions of the deceased in the       ground with carved headstones. Tombs of royalty or
spirit world.                                           heroes were often quite impressive and artistic, with
   Contrary to the Mesopotamian and Indus sim-          specialized artwork called sepulchral iconography. In
plification of death, the ancient Egyptians are         addition to bearing a brief inscription, a sepulchral
known for the dramatic in their preoccupation and       iconograph depicted the deceased performing some
near obsession with death and immortality. Prepa-       action or deed for the last time, plus showed the
rations for death were made carefully and long in       grief of the survivors. The ancient Greeks believed
advance: tomb chapels and burial chambers were          that such sepulchers possessed magical powers and
built, grave goods laid aside, and endowments set up    thus should be treated as shrines. Jocelyn Toynbee
to pay the mortuary priests who provided for the        (Death and Burial in the Roman World) asserts that the
eternal well-being of the deceased’s spirit. Specific    apparent transition in funerary iconography during
funeral customs varied over time and according to       the fourth century B.C.E. to more violent and grue-
class and wealth. About 2700–2200 B.C.E., the first      some themes and figures was the result of a new
great pyramids in “Old Kingdom” Egypt were con-         conception of death as a destructive process that
structed as tombs. Considered to be the first people     severs the deceased from the living.
to believe that the soul is immortal, the Egyptians         Similar to the Egyptians providing a Book of the
believed they would be resurrected after death to       Dead, the ancient Greeks enclosed information in
live forever, with death merely a transitional stage    the tomb of the deceased to help him or her nego-
along the way to a better life in the next world. The   tiate the underworld, ruled by Hades; this House of
Egyptian Book of the Dead (ca. 1600 B.C.E.) describes   Hades eventually become known as Hades. They
the travel of the soul into a next world without        also sent along coins, honey cakes, clothing, and
coming back to Earth. In order for the soul to func-    other items for entry into and use in the afterlife.
tion properly, the body must remain intact. When        The ancient Greeks did not practice embalming or
the body is in good condition after burying, the soul   mummification; the families of the dead prepared
returns to it again. Because of the importance of       the body for burial—bathing them, anointing them
keeping the body in good shape, along with the          with spices, perfumes, and oil to mask the odor of
need to prepare for the ensuing journey, the Egyp-      putrefying flesh, and dressing them. Clothing specif-
tians embalmed and mummified the dead, and pro-          ically for the dead and special flowers were provided
xx The Encyclopedia of Death and Dying

by friends and relatives. In the manner of future         males appear to have joined the ranks of their ances-
“wakes,” they waited three days and watched the           tors. Ideas regarding the nature of life after death are
body carefully to be sure the person really was dead.     not well developed in either the Hebrew Bible or in
The watching over the body also assured no harm           ancient Near Eastern texts, but death was clearly
would come to it prior to burial. What we would call      frightening, and the dead were associated with the
religious beliefs varied widely among the ancient         underworld. The most common burials during this
Greeks, but actual funeral rites seem to have been        time are in family tombs located in natural caves or
quite uniform. As early as the late eighth century        hewn chambers, approached by a shaft or passage-
B.C.E., the Greeks began to venerate the tombs of         way and closed with a single stone or pile of rubble.
heroes, who became immortal and dwelled with the          These tombs were used as burial vaults for the fam-
gods on Olympus, going so far as to attempt to            ily over several generations. As each new body was
restore their remains to their native cities. Cremation   placed in the tomb, previous burials were displaced,
came into practice for the Greeks about 300 B.C.E.        creating a jumble of intermixed bones and old offer-
    Ancient Romans used both cremation and burial,        ings on the periphery. Funeral offerings typically
with commoners more often buried and the aristo-          included jars containing grain, wine and oil, items of
cratic class opting for cremation, a status symbol        personal apparel and occasionally beds, tables, game
influenced by the Greeks and Etruscans. Cremation          boards, and other items of everyday life. These var-
became fashionable among aristocrats throughout           ied offerings point to a belief in the afterlife.
the Roman Empire and was the funeral mode of the              The ancient Israelites considered burial to be the
Caesars. In preparation for a Roman funeral, a group      only proper method of corpse disposal—often bury-
of slaves called pollinctores would wash the body daily   ing the body without even a coffin—and “decent”
for seven days with hot water and oil—the delay           burial was regarded to be of great importance. There
primarily to prevent premature burial. The body           is no explicit evidence as to how soon after death
would lie in state for viewing by the populace; those     burial took place, but it is likely that it was within a
who could afford it would hire a libitinarius to han-     day after death. This was dictated by the climate
dle the anointing or embalming, purchase special          and by the fact that the Israelites did not embalm
clothing for the dead, supply professional mourners       the dead (certain biblical persons, such as Jacob and
and mourning clothes, arrange for services aimed at       Joseph, were embalmed following Egyptian custom)
relieving the grief of the bereaved, and arrange for      because it was seen as mutilation of the body. Prepa-
the details of the funeral procession, which would        ration for burial consisted of wrapping the body and
usually be held at night to avoid defilement of the        the applying of oils and spices. In Talmudic times,
living. The wealthy would purchase elaborate urns         burial took place in caves, tombs carved out of rock,
for those to be cremated. At one point cremation          sarcophagi, and catacombs; and a secondary burial,
was forbidden within the gates of Rome because of         or re-interment of the remains, sometimes took
the smoke pollution of too many funeral pyres.            place about one year after the original burial.
    During these same ancient times, death and the            The practice of burial as the only means of corpse
proper treatment of the dead were important issues        disposition influenced early Christians, who dictated
for both the Canaanites (of ancient Palestine) and        that bodies were to be buried as a symbol of await-
Israelites, as they were for all the peoples of the       ing the resurrection, when they will rise from their
ancient Near East—attested to by frequent references      graves. In addition to saving the body for resurrec-
to burial in the Bible and other ancient writings, and    tion, the early Christian church also rejected cre-
by the presence of thousands of tombs, which modern       mation because of its association with pagan
archaeologists have excavated in the area. According      societies of Greece and Rome. With the rise of Chris-
to the University of Pennsylvania Museum of Archae-       tianity, its becoming the official religion of the
ology and Anthropology, appropriate arrangements          Roman Empire and its spreading through Europe,
included activities perpetuating the name of the          cremation stopped in Western Europe for a time.
deceased, offerings of food and other gifts, and the          Aiken writes that early Christian burial was with
proper stewardship of family land. Upon death,            the feet to the east, so that the “last trumpet,” which
                                                                                            Introduction xxi

would presumably be sounded from that direction,         priests, and perhaps legal representatives assembling
could best be heard and responded to more quickly.       around the bedside of the dying person. During
In addition, the placement of the head to the west       these rituals, which could last for days, grief was
symbolized the end of life.                              expressed, and personal, religious, and legal matters
                                                         were discussed. This encouraged dying persons to
                                                         put their worldly affairs in order so they could then
Death in the Middle Ages                                 die in peace with the knowledge that their last
The Middle Ages covered the period in European           wishes would be honored. The dying were expected
history that followed the fall of the Western Roman      to await death patiently, often holding a crucifix.
Empire (C.E. 475–600) and lasted into the 15th cen-      Those around the deathbed were warned not to give
tury or the beginning of the Italian Renaissance,        the dying person hope of recovery or to distract him
most often designated as somewhere between 1453          with talk of worldly possessions.
and 1500. Anxiety about death reached a peak in the          Even deaths on the battlefield during this period
Middle Ages, stimulated by numerous plagues, epi-        tended to be slow, usually, according to Jones, allow-
demics, wars, and the short life spans of this period.   ing the injured warrior to lie down facing Jerusalem,
Not only did adults consider their own deaths as         cross his arms over his chest, settle earthly accounts,
imminent, they also expected babies and children to      and say his prayers. A priest might be present to hear
die—because so many did. Life expectancy in En-          his confession and give absolution. “Finally, the
gland during the Middle Ages was 33 years. Thus,         medieval person—warrior or peasant—simply lapsed
death and dying were more visible during this period     into silence and waited for death.”
than they are today. Lewis Aiken notes that “publicly        Embalming was not condoned by the church
viewed executions, mortal skirmishes involving ordi-     during the early Middle Ages, but was resumed for
nary people, and mass epidemics that claimed the         royalty and nobility in the late 1200s and continued
lives of thousands were common occurrences. No           as such until the 1700s. Historians note that during
one knew when death might strike or even if it           this period, great advances were being made in
might happen before the day was over.” For exam-         medicine and bodies were needed for dissection pur-
ple, the Black Death killed between a quarter and a      poses, which would have meant a logical use of
half of the population of Europe during the 14th         embalming and even improved techniques in the
century.                                                 process. For example, Leonardo daVinci (1452–
    In characterizing attitudes toward the dead in the   1519) produced hundreds of anatomical plates as a
early Middle Ages, Philippe Aries speaks of the “tame    result of his dissection of the human body, using
death,” an inevitable, familiar, and orderly part of     arterial injection to preserve his specimens.
life, sometimes feared but never denied—an attitude          During the late Middle Ages, the church became
possibly carried forward from prehistory cultures.       a unifying institution, leading to a tremendous
    Because people of the Middle Ages were so inti-      boom in religious discussion of death and the after-
mately connected with death, they tended to see it       life. Although death remained a common and even
as a natural course and conclusion of their life on      anticipated experience, the Christian church viewed
Earth. Great importance was placed on a man’s            suicide as destroying something created by God. As
knowing that he was about to die so he could pre-        a result, the penalties for suicide were severe,
pare for it with final rituals. Unexpected, or sudden     including denial of Christian burial, degradation of
and accidental, death was most feared because it         the corpse, confiscation of the deceased’s posses-
would keep him from these preparations, and espe-        sions, and censure of the survivors.
cially from the last rites of the church, making             Reminiscent of the Egyptian Book of the Dead, the
damnation all the more likely. Because most major        Ars Moriendi (The art of dying), a book thought to
illnesses were fatal, death could be predicted with      have been written by German monks during the
some accuracy.                                           late Middle Ages, explained how to die in a digni-
    People frequently organized final rituals in their    fied, holy manner, providing both the dying person
own bedrooms, with family members, physicians,           and his or her relatives religious sayings and prayers
xxii The Encyclopedia of Death and Dying

for the deathbed, and answering questions about           do not appear in colonial burials before the begin-
salvation.                                                ning of English immigration to the area in the 18th
   The preoccupation with death during the late           century. Graves of the Spanish colonists occurred in
Middle Ages led to a preponderance of macabre art,        consecrated ground within or adjacent to a church.
with the human skeleton or a decaying corpse com-         They followed a pattern of regular, compact spacing
plete with maggots being used to personify death in       and east-facing orientation. These characteristics,
jewelry, woodcuts, poetry, and dramatic works. His-       together with arms crossed over the chest and the
torians have referred to the late Middle Ages as a        presence of brass shroud pins are a means of distin-
“wallowing” in death. Barbara Tuchman (A Distant          guishing Christian burials from precolonial Native
Mirror: The Calamitous 14th Century, 1978) argued         American burials.
that anxiety over the expected end of the world con-
tributed to the cult of the dead during the Middle
Ages. A belief in the approach of Judgment Day was
                                                          Native American Burial Customs
prompted not only by the massive number of deaths         The National Park Service tells us that Native Amer-
caused by war, disease, and famine during the 14th        ican burial customs have varied widely, not only
and 15th centuries but also by a widespread feeling       geographically, but also through time, having been
that sin was becoming rampant and that the human          shaped by differing environments, social structure,
soul was aging.                                           and spiritual beliefs. Prehistoric civilizations evolved
   Even during the Renaissance period (approxi-           methods of caring for the dead that reflected either
mately 1400–1650), characterized by a rebirth of          the seasonal movements of nomadic societies or the
the cultural and artistic life and a release of thought   life ways of settled communities organized around
and action from the strict theological dogmas of the      fixed locations. As they evolved, burial practices
Middle Ages, each individual was consumed with            included various forms of encasement, sub-surface
anxiety over his or her own death. Superstitions          interment, cremation, and exposure. Custom usually
and rituals practiced in medieval and Renaissance         dictated some type of purification ritual at the time
Europe included: holding a continuous bedside vigil,      of burial. Certain ceremonies called for secondary
known as a deathwatch; sounding a bell as the per-        interments following incineration or exposure of the
son died, known as a death knell; hanging wreaths         body, and in such cases, the rites might extend over
on the doors of the deceased’s home, and turning          some time period. Where the distinctions in social
mirrors toward the wall or covering them with black       status were marked, the rites were more elaborate.
cloth.                                                        The Plains Indians and certain Indians of the
   But the pessimism of the Middle Ages was turn-         Pacific Northwest commonly practiced above-ground
ing to optimism. Aiken writes that new geographi-         burials using trees, scaffolds, canoes, and boxes on
cal and scientific discoveries led people to believe       stilts, which decayed over time.
they could prevail against nature; thus the theme of          More permanent were earthen constructions,
human fortitude and competence in the face of             such as the chambered mounds and crematory
mortality, which had been seen in early Greek art,        mounds of the Indians of the Mississippi River
became fashionable again. There was a new confi-           drainage. In some areas of the Southeast and South-
dence that disease could be curbed.                       west, cemeteries for urn burials, using earthenware
   In the New World in 1565, the first lasting Euro-       jars, were common. After contact with European
pean community on the mainland of North Amer-             Americans, Native American cultures adopted other
ica was established by the Spanish on the east coast      practices brought about by religious proselytizing,
of Florida, at St. Augustine. An essential feature of     intermarriage, edict, and enforcement of regulations.
the fortified settlement was the Roman Catholic           The Hopi, Zuni, and other Pueblo peoples of Ari-
mission church with its associated burial ground.         zona and New Mexico were among the first to expe-
The archaeological record shows shroud-wrapped            rience Hispanic contact in the 16th century, and
interments were customary in the city’s Spanish           subsequently, their ancestral lands were colonized.
colonial period. Traces of coffins or coffin hardware       At the pueblos, stone and adobe villages where
                                                                                           Introduction xxiii

Roman Catholic missions were established, burials            In areas such as the Middle Atlantic region and
within church grounds or graveyards consecrated in       the South, settlement patterns tended to be more
accordance with Christian doctrine were encouraged       dispersed than in New England. Although early set-
for those who had been converted to the faith. How-      tlements such as Jamestown established church
ever, Native Americans also continued their tradi-       cemeteries, burial in churchyards eventually
tional burial practices, when necessary in secret.       became impractical for all but those living close to
   Throughout the period of the fur trade in the         churches. As extensive plantations were established
North Pacific, beginning in the late 18th century,        to facilitate the production of large-scale cash crops,
Russian Orthodox missions were established among         such as tobacco, several factors often made burial in
the native populations settled along the coastline       a churchyard problematical: towns were located far
and mainland interior of Russian-occupied Alaska.        apart, geographically large parishes were often
                                                         served by only a single church, and transportation
                                                         was difficult, the major mode being by water. The
Beginning of the Modern Era,                             distance of family plantations from churches neces-
1700–1850                                                sitated alternative locations for cemeteries, which
High death rates in Europe continued until the early     took the form of family cemeteries on the plantation
1700s, with the new century ushering in the age of       grounds. They usually were established on a high,
classical funeral monuments and dignified prose          well-drained point of land, and often were enclosed
epitaphs. Jupp and Gittings write that substantial       by a fence or wall. Although initially dictated by
headstones began to transform the appearance of          settlement patterns, plantation burials became a tra-
churchyards. The testimonies of countless funerary       dition once the precedent was set. Along with the
inscriptions and funeral sermons are complemented        variety of dependencies, agricultural lands, and
by descriptions of individual reactions to death in      other features, family cemeteries help illustrate the
some of the most intimately revealing of all English     degree of self-sufficiency sustained by many of these
diaries and private correspondence. The apogee of        plantations.
“rational religion” was followed by the beginnings of        In the young republic of the United States, the
evangelical revival.                                     “rural” cemetery movement was inspired by roman-
   In the American colonies, where religion formed       tic perceptions of nature, art, national identity, and
the very foundation and reason for being there for       the melancholy theme of death. It drew upon inno-
many, Laderman explains that the decaying corpse         vations in burial ground design in England and
held deep meaning, illustrating the wages of sin and     France.
serving as a humbling reminder to Christians of              Toward the end of the period in Europe, the
their inglorious fate. The corpse was “sacred,” the      church had begun to lose its control over burial mat-
rituals of burial clearly prescribed. Early Puritans     ters, as the church building began to lose its place as
rejected churchyard burials as they rebelled against     the central point of the death ritual, with an
other “papist” practices, as heretical and idolatrous.   increased use of secular burial places where pagan
Instead, many 17th-century New England towns set         symbolism could take over. In addition, the bereaved
aside land as common community burial grounds.           began to pay less attention to the spiritual fate of the
Headstone images from this period also reflect the        deceased, reducing the importance of a clerical pres-
rejection of formal Christian iconography in favor of    ence at the deathbed. Major movements of thought
more secular figures, such as skulls representing a       and feeling also transformed attitudes toward death:
fate common to all men.                                  the Enlightenment—a European intellectual move-
   The ideal during the colonial period in the other     ment that emphasized reason and individualism
English colonies was to bury the dead in church-         rather than tradition—and Romanticism—which
yards located in close proximity to churches.            emphasized inspiration, subjectivity, and the pri-
Churchyard burials remained standard practice into       macy of the individual—both had a profound
the 20th century for European Americans and other        impact on beliefs relating to the afterlife and the
cultures in the Judeo-Christian tradition.               experience of loss and bereavement. Jones explains
xxiv The Encyclopedia of Death and Dying

that the Romantics no longer feared the shellfire         easing the grief of the bereaved families. Laderman
and brimstone of their Puritan ancestors, but com-       explains that the industry’s rapid growth was made
pared death to the unfolding of a butterfly from its      possible by the experiences of northern families dur-
chrysalis. Large-scale urban mortality established       ing the Civil War. Prior to the war, embalming had
the need for new ways of dealing with the dead, and      negative associations for most Americans. The desire
a growing division between lower and upper classes       of northern families to have loved ones who had
increasingly commercialized death rituals.               perished on southern soil returned home for a
   The traditional Christian ideal of the “good death”   proper burial, however, led them to view the chem-
was still exceptionally powerful in England in I850,     ical preservation of the dead in a different light.
though its realization varied widely according to        Anxious to gaze once more at the familiar face of
class, religion, age, gender, and disease. Christian     their loved one, and aware of the impact the long
mourning rituals and the belief in family reunions in    journey home would have on the physical condition
heaven helped to reconcile some parents to high          of the corpse, bereaved families turned to under-
infant and child mortality. Moreover, the solace of      takers, who followed soldiers into the field to pre-
the private and social memory of the dead was com-       serve their bodies for shipment home. The growing
plemented by visible symbols of remembrance such         use of embalming during the Civil War years laid
as paintings, photographs and death masks of the         the foundation for the powerful funeral industry of
deceased, and mourning jewelry. Deathbed scenes          the 1880s and beyond.
became events of grand drama. Simple grave mark-             Several cultural trends also facilitated the rise of
ers went out of fashion as ornate tombstones, stat-      the funeral industry. The growing public respect for
ues, and monuments took their place.                     scientific principles and methods, and a new, very
   Prior to the Civil War in the United States, death    pronounced deference to professionally educated
typically took place in the home following a pro-        and trained “experts” were two such trends. Equally
tracted deathbed watch. Family members and               important, however, were the expansion of com-
neighbors would lay out, wash, and shroud the            mercial culture and the emergence of consumption
corpse. Viewing of the deceased also took place at       patterns broad enough to include the purchase of an
home, with the body going swiftly into the ground.       ever widening array of funeral services and prod-
Thus, death was close at hand, a common occur-           ucts. Thus, to a degree, Laderman writes, science
rence, and observed up close even by children.           and consumerism triumphed over organized reli-
   Although the setting was the home, certain            gion. In the place of the collective, shared public
aspects of the care of the dead began to be handed       meaning of death available to Christians in the colo-
over to persons outside the family: cabinetmakers        nial period, he argues, postbellum Americans sub-
began making the coffins, church sextons would lay        stituted private meanings shaped by a variety of
out and manage graveyards next to the church as          new consumer symbols and supradenominational
burial moved from home plots to graveyards, and          religious movements like Spiritualism. As the use of
livery service operators would hire out their wagons     embalming grew, the impracticality of embalming
to carry the deceased to the graveyard. Embalming        and restoring a body in the deceased’s home led to
was rarely done. This perspective on death and the       funeral parlors appearing toward the end of the
dead changed in the years prior to the Civil War as      19th century.
a dramatic shift occurred in the way Americans per-          Also following the Civil War, reformers con-
ceived and responded to death.                           cerned about land conservation and public health
                                                         agitated for revival of the practice of incineration
                                                         and urn burial. The cremation movement gathered
Emergence of the Funeral Industry                        momentum rapidly around the turn of the century,
By the time of the Civil War, some individuals—fre-      particularly on the west coast, and resulted in con-
quently the cabinetmakers who made the coffins—           struction of crematories in many major cities.
were “undertaking” the coordination of tasks that        Columbariums and community mausoleums were
needed to be done to complete funerals, as a way of      erected in cemeteries to expand the number of buri-
                                                                                            Introduction xxv

als that could be accommodated with the least sac-       jects that in 2010, 31 percent of deceased Americans
rifice of ground space.                                   will be cremated and 47 percent of Canadians, and in
                                                         2025, 49 percent. According to the Cremation Soci-
                                                         ety of Great Britain, in the year 2000, cremations
Death Practices in the Twentieth                         took place in 71 percent of all funerals there. In
Century, Today and Tomorrow                              other countries, such as Japan and Scandinavia, cre-
Perpetual care lawn cemeteries or memorial parks         mations reach as high as 95 percent.
in the 20th century transformed the rural cemetery           Along with body disposition, death itself has also
ideal of the previous century. A new lawn plan sys-      changed markedly this past century. Throughout his-
tem deemphasized monuments in favor of unbro-            tory and until quite recently, medical science could
ken lawn scenery, or common open space. Modern           do little to prevent or cure life-threatening illnesses.
cemetery planning was based on the keynotes of           Many people died young; infant death was com-
natural beauty and economy. Whereas 19th-century         monplace. In 1900, 30 percent of the people who
community cemeteries typically were organized and        died were age five or younger; the life expectancy
operated by voluntary associations that sold indi-       was only 50, with the average age of death 46, and
vidual plots to be marked and maintained by private      only a few lived beyond age 85. By 1999, the per-
owners according to individual taste, the memorial       centage of people dying before five years of age had
park was comprehensively designed and managed            dropped to about 1 percent. Today, the “old-old,”
by full-time professionals. Whether the sponsoring       those 85 and over, are the most rapidly growing sec-
institution was a business venture or nonprofit cor-      tor of the aged. By the year 2050, people over 85 are
poration, the ideal was to extend perpetual care to      expected to number over 19 million, making up 24
every lot and grave. The natural beauty of cemetery      percent of older persons and 5 percent of the entire
sites continued to be enhanced through landscap-         population in the United States. Today, three-fourths
ing, but rolling terrain was smoothed of picturesque     of those who die annually are older adults.
roughness and hilly features. The mechanized                 Along with this “aging” of death has come a dra-
equipment required to maintain grounds efficiently        matic change in the causes of death. In 1900, the 10
on a broad scale prompted standardization of mark-       leading causes of death were pneumonia, tubercu-
ers flush with the ground level and the elimination       losis, diarrhea and enteritis, heart disease, stroke,
of plot-defining barriers.                                liver disease, injuries, cancer, senility, and diphthe-
    In 1963, Jessica Mitford’s best-selling The Ameri-   ria. Most people died from infectious illnesses that
can Way of Death exposed the avarice and commer-         caused death with certainty and relative rapidity. In
cialism of the American funeral industry at that         2001, the 10 leading causes were heart disease, can-
time, demonstrating that death practices in the          cer, stroke, chronic lung diseases, accidents, dia-
United States were among the most costly and elab-       betes, pneumonia and influenza, Alzheimer’s
orate in the world, and that funeral expenses had        disease, kidney diseases, and blood poisoning. It has
been rising faster than the general cost of living.      been estimated that 70–80 percent of people in
Spurred by the public outcry because of Mitford’s        advanced industrial nations now face death later in
exposé, the funeral industry did begin to reform its     life from chronic or degenerative diseases charac-
sales practices, and eventually the Federal Trade        terized by late, slow onset and extended decline.
Commission set up the Funeral Rule.                          Where people die is also different today. Less
    Even with a general clean-up of the industry,        than a generation ago, dying still often took place at
funeral costs have remained high, which, combined        home and among family. It was more of a religious
with general concern about land use, has caused the      experience than a medical one, with the doctor
number of cremations in North America to increase        needed only to officially pronounce the passing.
dramatically in recent years: from 5 percent in 1962     Because many deaths occurred at home, people
to 20 percent in 1992. In 2000, 26 percent of Amer-      were likely to care for dying relatives and, thus, to
icans and 45 percent of Canadians were cremated.         have a fairly personal and direct experience with
The Cremation Association of North America pro-          dying and death.
xxvi The Encyclopedia of Death and Dying

    Today the typical place of death has changed to       many middle-aged adults, whose parents are reach-
technologically sophisticated and often impersonal        ing advancing age, have never cared for nor even
settings. It has been estimated that in the United        been in contact with a person who is dying. Not
States nearly 76 percent of all deaths occur in hos-      only are they unfamiliar with the process; they have
pitals, medical centers, or nursing homes. Only a         no firsthand knowledge of the issues and what must
minority of people die in the care of formal hospice      be considered. Because of all these cultural changes
programs, and the majority of these hospice deaths        and differences in dying, end-of-life issues are
involve cancer diagnoses. But even this is changing.      receiving major attention from researchers and
More recently, the proportion of those who die at         practitioners in the fields of medicine, psychology,
home has begun to increase because changes in             sociology, ethics, law, economics, and religion.
Medicare benefits have led to increased availability
of home hospice services.
    Medical treatments can now control “immediate
                                                          Within This Book
killers” such as pneumonia and kidney failure that        This encyclopedia is divided into two basic sections—
accompany cancer, heart disease, and other “slow          first is the A to Z main body, second is the Appendix
killers.” Thus, with death from these conditions          section. Within the alphabetical body of the book,
postponed, questions about life-prolonging treat-         you will find more than 560 terms related to the
ment become central issues for patients, their fam-       history, culture, religion, economics, sociology, laws,
ilies, their caregivers, and the wider community of       and medical aspects of death and dying. Any terms
ethicists, lawyers, and sociologists. All 50 state leg-   used within a listing that have their own separate
islatures have addressed these issues in recent years,    listings are designated with small capital letters so
leading to a whole new body of end-of-life laws.          that you can quickly and easily find expanded infor-
    In August 2000, the National Institutes of Health     mation. Also, many listings end with references to
(NIH) called on the scientific community to “seek          articles and books on the topic for further study.
research grant applications that will generate scien-         The Appendixes include organizations and
tific knowledge to improve the quality of life for indi-   groups that offer information and support, Internet
viduals who are facing end-of-life issues and for their   Web sites offering resources and help; bibliographies
families. For many Americans, end-of-life care is frag-   of books, articles, and videos; a sample advance care
mented, painful, and emotionally distressing, with        document, end-of-life and funeral preplanning
unnecessary transitions between health care institu-      checklists, the odds of dying from various acciden-
tions, community-based organizations and home             tal injuries, leading causes of death for various pop-
care settings. There are opportunities for health care    ulation groups, suggested end-of-life care at home,
providers to learn more about how to deliver optimal      where to write for death certificates, America’s war
end-of-life care.” A study published in the Journal of    death statistics, and death care industry and con-
the American Medical Association (JAMA) found that of     sumer organizations, among other lists and tables.
50 medical textbooks reviewed, about a quarter had            Overall, you will find a comprehensive overview
helpful information on likely end-of-life subject         of death and dying, with in-depth treatment of cur-
areas, but 19 percent gave the subject minimal atten-     rent end-of-life issues, in an easy-to-access format,
tion, and 57 percent none at all.                         and with plenty of assistance on where to go next
    With today’s surge in nursing home care, com-         for additional information on this topics of particu-
pounded by a more geographically-dispersed family,        lar significance to you and your family.
ENTRIES A–Z
                                                                                                              A
abandonment of the dying         Abandonment of the              1.6 million in 1990). According to research conducted
dying is a term used by those opposed to ASSISTED                by the Alan Guttmacher Institute, a nonprofit organ-
SUICIDE, especially by those involved in the HOSPICE             ization focused on sexual and reproductive health
model of care. Hospice advocates and religious ethi-             research, policy analysis, and public education, 49
cists use this phrase to enforce their feeling that              percent of pregnancies among American women are
helping people die is a failure to adequately address            unintended and half of these are terminated by abor-
patients’ fears and alleviate their suffering. George            tion. From 1973 through 2000, more than 39 million
Webster, a bioethicist at St. Michael’s Hospital in              legal abortions occurred. Each year, two out of every
Toronto, used the term when he stated that                       100 women aged 15 to 44 have an abortion; 48 per-
“euthanasia or assisted suicide can be nothing other             cent of them have had at least one previous abortion
than the ultimate abandonment of the dying.”                     and 61 percent have had a previous birth. Each year,
   Used in another context, Gilbert writes, “Any                 an estimated 46 million abortions occur worldwide.
ANTICIPATORY GRIEF that takes place will inevitably              Of these, 20 million procedures are obtained illegally.
involve withdrawal from and possible abandon-                       The Alan Guttmacher Institute also reports that
ment of the dying person.”                                       52 percent of U.S. women obtaining abortions are
   Physicians have also been accused of abandon-                 younger than 25 and 19 percent under age 20.
ment of the dying when “confusing care with cure”                Black women are more than three times as likely as
and assuming that because they can no longer cure                white women to have an abortion, and Hispanic
patients, they cannot care for them.                             women are two-and-a-half times as likely. Two-
                                                                 thirds of all abortions are among never-married
Gilbert, Kathleen R. “Unit 11—Anticipated Losses and             women. Over 60 percent of abortions are among
   Anticipatory Grief.” Grief in a Family Context, Indiana       women who have had one or more children.
   University, February 1996.                                       On average, women give at least three reasons
                                                                 for choosing abortion: three-fourths say that having
                                                                 a baby would interfere with work, school, or other
abortion An abortion is a procedure to end a preg-               responsibilities; about two-thirds say they cannot
nancy by removing the embryo (first eight weeks                   afford a child; and one-half say they do not want to
after conception) or fetus (end of eighth week                   be a single parent or are having problems with their
through birth) and placenta from the uterus before               husband or partner.
the fetus is “viable” or capable of living; also called             A political hot button today, abortion has “long
induced abortion. Elective abortions are those initi-            been the subject of moral and legal controversy
ated by personal choice. Therapeutic abortions are               owing to disagreement about what constitutes a liv-
those recommended by a medical doctor in order to                ing human being and when life actually begins,”
protect the mother’s physical or mental health.                  according to Ammer.
When a fetus aborts naturally or spontaneously, it is               Humanists, for example, do not consider an
commonly referred to as a MISCARRIAGE.                           embryo or fetus to be a person, but rather, to have
   In 2000, 1.3 million women in the United States               the potential of becoming one. They see the abortion
had an induced abortion (down from an estimated                  decision as a personal, moral choice for the woman

                                                             1
2 abortion

and not properly the subject of criminal legislation.      Sogyal Rinpoche writes that the consciousness of
At the opposite end, those who believe that a life is      those who die before birth will take on another exis-
created at the moment of conception regard abortion        tence. “If the parents feel remorse they can help by
as equivalent to murder.                                   acknowledging it, asking for forgiveness, and per-
   According to Ammer, “Many other views have              forming ardently the purification practice of
prevailed, ranging from the idea that life begins          Vajrasattva. They can also offer lights, and save lives,
when a fetus’s movements first are felt (St. Thomas         or help others, or sponsor some humanitarian or spir-
Aquinas), to a particular time period after concep-        itual project, dedicating it to the well-being and
tion (Aristotle said 40 days for boys and 90 days for      future enlightenment of the baby’s consciousness.”
girls), to after delivery (the ancient Hebrews).”             In the United States, in addition to being influ-
   Abortion has, in fact, been practiced throughout        enced by moral, religious, and social values, the issue
history—at times legally and tolerated even by reli-       of abortion has also been “shaped by racism, femi-
gious bodies, at other times crudely and outside the       nism, and class dynamics,” according to Ammer.
law. The patterns of abortion as a method of dealing       “Philadelphia surgeon Dr. Everett Koop, the antiabor-
with unwanted pregnancies have been strikingly             tion activist who was to serve as Reagan’s Surgeon
similar throughout history and across societies, as        General, observed: ‘Nothing like it has separated our
noted in Abortion in Law, History & Religion:              society since the days of slavery.’”

   In primitive tribal societies, abortions were induced                        The Procedure
   by using poisonous herbs, sharp sticks, or by sheer     Research shows that the risk of abortion complica-
   pressure on the abdomen until vaginal bleeding          tions is minimal—less than 1 percent of all abortion
   occurred. Abortion techniques are described in the      patients experience a major complication—making it
   oldest known medical texts. The ancient Chinese         safer than pregnancies carried to term. The risk of
   and Egyptians had their methods and recipes to          death associated with abortion increases with the
   cause abortion, and Greek and Roman civilizations       length of pregnancy, from one death for every
   considered abortion an integral part of maintaining     530,000 abortions at eight weeks or earlier, to one
   a stable population. Ancient instruments, such as       per 17,000 at 16 to 20 weeks, and one per 6,000 at
   the ones found at Pompeii and Herculaneum, were         21 or more weeks. The risk of death associated with
   much like modern surgical instruments. The Greeks       childbirth is about 10 times as high as that associated
   and Romans also had various poisons administered        with abortion.
   in various ways, including through tampons.                According to the American College of Obstetri-
       Socrates, Plato and Aristotle were all known to     cians and Gynecologists, induced abortion can be
   suggest abortion. Even Hippocrates, who spoke           done in several ways. The method depends on the
   against abortion because he feared injury to the        patient’s choice, health, and length of time she has
   woman, recommended it on occasion by prescrib-          been pregnant.
   ing violent exercises. Roman morality placed no            Medical abortion A medical abortion can be
   social stigma on abortion.                              done within 49 days from the first day of the
       Early Christians condemned abortion, but did        woman’s last menstrual period. It usually involves
   not view the termination of a pregnancy to be an        several doctor visits and two sets of drugs in pill form:
   abortion before “ensoulment”—the definition of
   when life began in the womb. Up to 400 A.D., as the     • Mifepristone (trade name Mifeprex and also
   relatively few Christians were widely scattered geo-      called RU-486, its French name) blocks the action
   graphically, the actual practice of abortion among        of the hormone progesterone.
   Christians probably varied considerably and was         • Misoprostol, a prostaglandin, causes the uterus to
   influenced by regional customs and practices.              contract and expel the embryo through the vagina.

   When explaining the Buddhist beliefs concerning         Developed by a French pharmaceutical firm, RU-486
abortion in The Tibetan Book of Living and Dying, author   was first approved for use in France in 1988. After
                                                                                                    abortion 3

clinical trials in the United States and France, the       which then suctions out the fetus, the placenta, and
Food and Drug Administration approved mifepris-            other uterine contents. After the suctioning, the
tone for the termination of early pregnancy on Sep-        physician may find it necessary to use a curette (a
tember 29, 2000, amid controversy and concern              sharp, spoon-like instrument) to gently scrape the
that it would lead to even more abortions. Despite         walls of the uterus to make sure all the fragments of
that anxiety, a study released in 2003 by the Alan         the fetus and placenta have been removed from the
Guttmacher Institute, showed that medical abor-            uterus.
tions using drugs in the first seven weeks of preg-             The procedure usually takes 10 to 15 minutes.
nancy remain a tiny portion of all abortions. Among        Uterine cramping may occur afterward. After an
the reasons given: higher cost, time-consuming, and        hour or so of observation following the procedure,
potential for bleeding (for as long as two weeks,          if the patient is not experiencing heavy bleeding or
compared to little or no bleeding after surgical           other complications, she is able to leave. Complica-
abortion).                                                 tions may include infection, heavy bleeding, perfo-
    Menstrual aspiration (also called minisuction,         ration of the uterus (a hole or tear in the wall of the
miniabortion, vacuum aspiration, lunchtime abor-           womb), cervical incompetence (a condition in
tion) Menstrual aspiration can be done within one          which the cervix opens up too early in future preg-
to three weeks after a missed menstrual period. Per-       nancies, increasing the risk of a miscarriage in
formed on an outpatient basis, this procedure              future pregnancies), and injury to the cervix.
involves a thin plastic tube being inserted into the       Repeated abortions could increase the possibility of
uterus and its contents sucked out via a syringe.          premature delivery or a low-birth-weight infant in
The procedure takes about 10 minutes to complete.          future pregnancies.
It is done without anesthesia, surgical risks are min-         Dilation and evacuation D&E is done in the sec-
imal, and the patient resumes her normal activities        ond 12 weeks (second trimester) of pregnancy. It
when she leaves the office.                                 usually includes a combination of vacuum aspira-
    Suction curettage Suction curettage removes            tion, dilation and curettage (D&C), and the use of
the contents of the uterus by a suction device that        surgical instruments, such as forceps. It routinely
is inserted into the uterus. It also is sometimes called   takes about 30 minutes and is usually done in a hos-
vacuum curettage. It can be done up to 12 weeks of         pital, although an overnight stay is not normally
pregnancy, and is the most common procedure used           required.
for abortion during the first trimester.                        Labor-inducing abortion For abortions later in
    Unless unusual circumstances exist, this proce-        pregnancy, labor may be induced with drugs. Labor-
dure is done on an outpatient basis and may be             inducing abortions are almost always done in a
done in a physician’s office or a clinic. The doctor        hospital.
first widens (dilates) the cervix (the opening of the
uterus). It may take several hours and may be done                           Emotional Effects
by the physician inserting a small rod or sponge           Whether the reason for the abortion is health or
into the cervix, which swells as the sponge absorbs        personal choice, it is not unusual for the woman
moisture. Or, the doctor may choose to enlarge the         undergoing the abortion to feel some emotional
cervix right before the abortion by inserting and          effects because of the resultant “death.” The inten-
withdrawing larger and larger smooth metal rods            sity and duration of these emotions vary from
until the cervix has been opened to the necessary          woman to woman. Some will feel relief; others
size. Most women experience some pain, so the              anger or guilt; still others depression. It is a normal
physician will administer a pain-killer, either locally    grieving process compounded by natural hormonal
by shots in the area of the cervix or, on rare occa-       changes that occur with any pregnancy. For most
sions, by a general anesthetic.                            women, this occurs for a short period of time. If
    After dilation, a plastic tube about the diameter      symptoms of sleep disturbance, loss of interest in
of a pencil is then inserted into the uterus through       work or sex, or anger are persistent or remain
the enlarged cervix. The tube is attached to a pump        intense, professional counseling may be needed.
4 accelerated death benefits

    In an uncontrolled British study of women who                   Outcomes Summary of Empirical Research between
had terminated their pregnancies for genetic                        1966 and 1988.” Health Care for Women International, 10,
(defect) reasons, three in four (77 percent) of the                 no. 4 (1989): 347–376.
mothers developed ACUTE GRIEF REACTION. Forty-six
percent remained symptomatic six months after ter-
mination; some required psychiatric support. A                   accelerated death benefits (ADB)             Some life
more recent case-control study evaluating the grief              insurance policies have an accelerated death bene-
responses of women who terminated their preg-                    fits option (or rider), which allows advance pay-
nancies for fetal anomalies concludes that “women                ment of some portion of the death benefit while
who terminate pregnancies for fetal anomalies                    the insured person is still alive, should the insured
experience grief as intense as those who experience              suffer from a terminal illness as defined by the pol-
spontaneous perinatal loss, and they may require                 icy. The intent of ADB is to provide funds to meet
similar clinical management.”                                    extraordinary living, medical, or hospice expenses
    The extent of emotional or psychological stress              during the insured’s final days. In most policies con-
resulting from an abortion is as hotly debated as the            taining this option, the insurance company will pay
life-choice issue itself. When studies over time led to          the insured a portion (usually 50–80 percent) of
a general consensus among medical communities                    the policy’s face value, minus any outstanding pol-
that most women who have abortions experience                    icy loans. The insured is usually eligible if he or she
little or no psychological harm, right-to-life advo-             has 12 months or less to live and added this option
cates countered with other studies showing that                  to the life insurance policy prior to becoming ter-
most women who have abortions will suffer to some                minally ill. A few companies’ life expectancy
degree from a variant of post-traumatic stress disor-            requirements may range to two years. In some
der called “post-abortion syndrome”—a condition                  states and with some policies, ADB is payable when
not recognized by psychiatric or psychological                   the insured requires long-term care or confinement
groups. The continued discrepancies and criticisms               to a nursing home. Accelerated death benefits are
from both sides of the other’s methodological flaws               sometimes referred to as “living benefits.”
draw attention to the need for more long-term, in-                  Accelerated death benefits began in 1988 as a way
depth prospective studies.                                       of giving terminally ill AIDS patients a portion of
                                                                 their life insurance proceeds. It has since expanded to
Abortion in Law, History & Religion. Toronto: Childbirth by      include other terminal and chronic illnesses. By 1998
   Choice Trust, 1995.                                           an estimated 40 million individual or group policies
“Abortion Procedures” Michigan Department of Commu-              included an ADB option. Approximately 75 percent
   nity Health. URL: http://www.michigan.gov/mdch/               of insurance companies offer the ADB option,
   0,1607,7-132-2940_4909-46328—,00.html Down-                   although it is not available for all types of policies.
   loaded on July 9, 2004.                                       Each company’s plans are different; some will include
Ammer, Christine. “abortion,” in The New A to Z of Women’s       ADB only with a new policy, while others will add
   Health, Fourth Edition. New York: Facts On File, 2000.        riders to certain existing policies. Some companies
Arthur, Joyce. “Psychological After-Effects of Abortion: The     charge additional premiums for ADB coverage; oth-
   Real Story.” The Humanist 57, no. 2 (March/April 1997).       ers offer it at no additional premium, but impose an
Lloyd, J., and K. M. Laurence. “Sequelae and Support             interest charge and/or a service fee when the bene-
   after Termination of Pregnancy for Fetal Malforma-            fit is paid. The interest charge is deducted either from
   tion.” British Journal of Medicine (Clinical Research Edi-    the accelerated payment or from the final death ben-
   tion) 290, no. 6472 (March 23, 1985): 907–909.                efit. Most life insurance companies limit the amount
Ney, P. G., and A. R. Wickett. “Mental Health and Abortion:      of death benefit that can be accelerated, by restricting
   Review and Analysis.” Psychiatric Journal of the University   either the percentage of the death benefit or the dol-
   of Ottawa 14, no. 4 (November 1989): 506–516.                 lar amount received.
Rogers, James L., George B. Stoms, and James L. Phifer.             When an individual has a policy with this option
   “Psychological Impact of Abortion: Methodological and         and wants to implement it, the insured or close fam-
                                                                                                      acceptance       5

ily member must contact the life insurance company            acceptance Acceptance is the fifth and final stage
that issued the ADB option. The company will out-             that people go through upon learning they are dying,
line what is needed to prove the insured is terminally        according to ELISABETH KÜBLER-ROSS. It involves a
ill or has a qualified covered condition. Payment              coming to terms with the situation without feelings of
choices may include either a lump sum or monthly              hostility, and allows time for facing reality in a con-
payments, although lump sum is the most frequent              structive way. Kübler-Ross described acceptance as
option. Some states, such as Illinois, also let life insur-   the ideal stage of death. The patient says, “I have fin-
ance companies pay up to a specified percentage                ished all, till now, unfinished business. I’ve said all the
(such as 75 percent) of the policy’s face value for cer-      words that had to be said. I am ready to go.” Unlike
tain medical conditions, such as heart attack,                those who remain angry and depressed, “patients
Alzheimer’s disease, or major organ transplant.               who are in the stage of acceptance show a very out-
    Important considerations when contemplating               standing feeling of equanimity and peace. There is
an ADB payout:                                                something very dignified about these patients.”
                                                                 In his critique of Kübler-Ross, Kuykendall coun-
• After the insured’s death, the policy may no                ters that “Since, in the psychoanalytic perspective,
  longer pay the intended beneficiary any death                one can never move far beyond the limits set by the
  benefit, or it may pay a much lower benefit than              unconscious, it is impossible to come to a final, peace-
  the policy was originally planned to cover.                 ful acceptance of death. Rather, dying individuals are
• If the insured owes money, creditors may try to             inevitably torn between the inescapable reality of
  collect what he or she owes them from such life             impending death and the intolerability of the idea of
  insurance payouts.                                          dying; consequently, they experience great unrest
                                                              and anxiety.”
• Advance payments from life insurance may affect
                                                                 In his review of her works, Branson writes that
  the insured’s eligibility for programs such as Med-
                                                              throughout her books “Kübler-Ross charges medical
  icaid and supplemental Social Security income.
                                                              personnel, and even relatives, with communicating
  The U.S. Department of Health and Human Ser-
                                                              to the dying patient their own fear of and hostility
  vices and the Centers for Medicare and Medicaid
                                                              toward death—‘I think most of our patients would
  Services (formerly the Health Care Financing
                                                              reach the stage of acceptance if it were not for the
  Administration) have rules that an insured can-
                                                              members of the helping professions, especially the
  not be forced to request or collect accelerated
                                                              physicians, who cannot accept the death of a
  death benefits before qualifying for Medicaid ben-
                                                              patient . . . the second and quantitatively more fre-
  efits. But once accelerated death benefits are
                                                              quent problem is the immediate family which
  elected, those funds could be considered income
                                                              “hangs on” and cannot “let go.”
  when determining for Medicaid eligibility.
                                                                 Comparing the Kübler-Ross philosophy to Soc-
• Under federal income tax law affecting payments             rates, Branson says, “Socrates displays total calm, an
  received during 1996 and earlier, living benefit             acceptance of death that the Stoics considered the
  payments were subject to federal income tax.                essence of dignity.”
  Under Public Law 104–191, the Health Insur-                    Death and bereavement counselor San Filippo
  ance Portability and Accountability Act of 1996,            asserts that “through the attainment of an under-
  Subtitle D, Treatment of Accelerated Death Ben-             standing and acceptance of death, life can be lived
  efits, living benefit payments received after               more fully and death can come more peacefully.”
  December 31, 1996, will not be subject to federal              See also ANGER; BARGAINING; DENIAL; DEPRESSION.
  income tax. However, many states have laws,
  regulations, or rulings concerning the taxability           Branson, Roy. “Is Acceptance a Denial of Death? Another
  of accelerated death benefits as applied to state               Look at Kübler-Ross.” The Christian Century (May 7,
  income taxes.                                                  1975): 464–468.
                                                              Kuykendall, George. “Care for the Dying: A Kübler-Ross
   See also VIATICAL SETTLEMENT.                                 Critique.” Theology Today 38, no. 1 (April 1981): 37–48.
6 acceptance phase of grief

San Filippo, R. David. “Acceptance of Death.” Lutz-San            2000, or 4.1 percent of the deaths from all causes,
   Filippo Counseling Library. Available online. URL: http://     ranking accidental deaths fifth as a cause of death.
   www.lutz-sanfilippo.com/library/lsfacceptancedeath.            The accidental death rate was 35.6 deaths per
   html. Posted April 14, 1991.                                   100,000 population.
                                                                • By far, the most frequent cause of accidental
                                                                  death in the United States in 2000 was motor
acceptance phase of grief      During this final stage,            vehicle accident (43,354), followed by falls
the grieving person is at last able to face the reality           (13,322), accidental poisoning (12,757), drown-
of the loss of a loved one calmly and with a resig-               ing (3,482), fires and burns (3,377), boating and
nation that allows an acceptance of that loss. The                airplane (1,903), other land vehicle (1,492),
anger, sadness, and mourning have gradually                       firearms (776).
diminished. The person now begins to move on.
Although the survivor will probably never forget                • According to the National Safety Council, the
the one who is gone, the realization sets in that he              odds of dying from an accidental injury in 1999
or she has to say farewell, and return to the living.             were one in 2,788. The lifetime odds of dying
   While comparing Kübler-Ross’s stages of dying                  from an accidental injury for a person born in
with the similar stages people go through when                    1999 were one in 36.
grieving the death of others, Jones refers to the               • May through August account for nearly half of all
stage following despair and struggle coping as the                injury-related childhood deaths, with July being
acceptance of the reality of a loved one’s death and              the deadliest month, according to a study com-
the beginning of healing. “Survivors begin to                     pleted by the National Safe Kids Campaign. Dur-
become interested in life again. Food tastes good                 ing the summer months, when children are out
again. They are able to laugh and enjoy friends and               of school, lack adequate supervision, and spend
family more often. They think of their (departed)                 more time outdoors, the risks to children are
loved ones without feeling overwhelming sadness.                  heightened. Drowning is the greatest summer
They even feel like they learned something from                   risk for children ages 14 and under, increasing
their loss.”                                                      96 percent above average during the summer.
   See also GRIEF; THE GRIEVING PROCESS.                        • Throughout the year, accidental injury is the
                                                                  number one cause of death across the nation for
Jones, Constance. R.I.P.: The Complete Book of Death & Dying.     children 14 years and younger.
   New York: HarperCollins, 1997.
                                                                • More than 1,800 children age 13 or younger died
                                                                  in motor vehicle accidents in 2000. The number
                                                                  of deaths was 60 percent higher from June to
accidental death      Accidental death is sometimes
                                                                  August than during the winter, largely because
defined legally as “unintended and essentially
                                                                  more people are on the road. During the week,
unavoidable death, not by natural, suicidal or homi-
                                                                  half of all motor vehicle deaths suffered by chil-
cidal means.” As defined by the Social Security
                                                                  dren occur between Friday and Sunday.
Administration, an accidental death is a death: (1)
resulting directly from bodily injuries, independent of         • Nationwide, accidental deaths of children 14 and
all other causes, which were received solely by vio-              under totaled 40,240 from 1991 to 1996, accord-
lent, external, and accidental means; and (2) occur-              ing to the National Safe Kids Campaign study.
ring within three months after the day on which the             • In the United States, more than half of all acci-
injuries were received. In compiling its own statistics,          dental deaths among people aged 65 years and
the National Safety Council considers accidental any              older (more than 16,000 deaths each year) are
death that occurs within one year of the accident.                caused by motor vehicle crashes and uninten-
                                                                  tional falls, but a CDC study found differences in
• The National Center for Health Statistics reported              rates among ethnic groups and between genders
  97,902 accidental deaths in the United States in                in this age group. Motor vehicle–related death
                                                                                             acute grief reaction 7

  rates for men were highest among American                    They argue that AD&D creates the illusion of hav-
  Indians and blacks. Death rates for women were               ing much greater insurance protection than one
  highest among American Indians and Asians, and               actually holds. They advise putting the premium
  lowest among blacks. Older Asian women had                   funds into other forms of insurance that cover death
  motor vehicle–related death rates nearly twice               from any cause.
  those of black women. Fall-related death rates                  In the early 1900s accident insurance coverage
  for both men and women were highest among                    was restricted to men as a means of replacing their
  whites. Rates were lowest among blacks and                   lost income and to the few women who were their
  about half the rate of whites. Non-Hispanics con-            families’ sole support. According to Perez, “One of
  sistently had higher fall-related death rates than           the first accident policies, which sold for about two
  Hispanics.                                                   cents, covered a Connecticut businessman’s four-
                                                               block walk from his home to the post office.” When
Kane, B. E., A. D. Mickalide, and H. A. Paul. Trauma Sea-      air travel became more common during the 1950s,
   son: A National Study of the Seasonality of Unintentional   employers began carrying accidental death insur-
   Childhood Injury. Washington, D.C.: National SAFE           ance on their employees who traveled frequently.
   KIDS Campaign, 2001.                                        Today, with general insurance costs climbing, fewer
SSA’s Program Operations Manual System. “GN 00305.105          employers offer extensive employee coverage pack-
   Accidental Death.” Social Security Administration.          ages, so AD&D coverage has become an important
   Available online. URL: http://policy.ssa.gov/poms.nsf/      personal insurance product for the insurance
   lnx/0200305105. Last updated May 10, 2001.                  industry.
Stevens, Judy A., and A. M. Dellinger. “Motor Vehicle             Over time, basic AD&D coverage has expanded,
   and Fall-Related Deaths among Older Americans               with many companies now including in it benefits
   1990–98: Sex, Race, and Ethnic Disparities.” Injury Pre-    such as bereavement and trauma counseling, and
   vention 8, no. 4 (December 2002): 272–275.                  child care expenses for a period of years if an
                                                               insured spouse dies as a result of a covered accident.

accidental death and dismemberment (AD&D)                      Perez, Anthony. “Accident Coverage Evolves with Rapidly
insurance Insurance companies offer insurance                     Changing World.” Employee Benefit News 16, no. 8 (June
coverage that provides payment if the insured’s                   15, 2002): 20–21, 51.
death results from an accident, or if the insured
accidentally severs a limb above the wrist or ankle
joints, or totally and irreversibly loses his or her           acute grief reaction      A normal and understand-
eyesight. The accidental death portion may be                  able reaction to loss, acute grief is an intense wave
offered as an Accidental Death Benefit Rider, which             of grief that can occur at any time from immediately
is a life insurance policy add-on providing for pay-           following the loss up to 12 months later. This
ment of an additional cash benefit related to the               intense feeling may wane, then reappear. Despite
face amount of the base policy when death occurs               the best efforts of health care providers and careful
by accidental means. AD&D insurance coverage is                attention to ANTICIPATORY GRIEF, some family mem-
lower in cost than traditional life insurance that             bers will experience dramatic and disturbing acute
pays for any and all causes of death because the               grief reactions. These reactions may include denial,
risk to the insurance company that the insured will            intense crying spells, anxiety, and physical symp-
die accidentally is much less than the risk that he or         toms that may be distressing to family and
she will die at all during the life of the policy.             providers.
    Because of the lower risk that the insured will die           Zerbe and Steinberg describe the symptoms of
as a result of an accident, rather than disease or             acute grief reaction as including: numbness or
other “natural” causes, or the lower risk of losing a          “dampened” emotions; temporary loss of self-
limb compared to suffering a crippling injury, many            esteem, which generally returns to normal quickly;
financial experts consider AD&D a poor investment.              anger; anxiety; impaired concentration and short-
8 adolescents and grief

term memory; turbulent mood swings; preoccupa-               upsets that image of remoteness. Understanding and
tion with the deceased; vivid images of the dead             accepting the death of a peer is especially difficult for
person, especially when drowsy (these are not a              adolescents. The death of another adolescent tends
sign of psychosis); mild dissociative experiences;           to affirm the possibility of one’s own death.
urge to search for the deceased; restless sleep; and            After the Columbine Massacre in 1999 and the
increased physical preoccupations.                           September 11, 2001, attacks, concerns arose about
   According to the World Health Organization,               how adolescents would deal with such tragedy.
physicians should avoid prescribing medication for           According to Christ et al., “Violent death may cause
acute grief reaction if possible. If the grief reaction      more frequent traumatic stress responses with
becomes abnormal (lasts longer than two weeks at             intense fears of personal safety, intrusive frightening
a time or persists beyond six months) and depres-            images, feelings of guilt, and beliefs that death could
sion is a concern, antidepressant and/or tranquiliz-         have been prevented or must be avenged. Usually
ing drugs may be prescribed.                                 such responses are transient, but in some they
   An acute grief reaction may also occur in the             remain, leading to more severe psychopathology
patient who knows he is dying.                               such as posttraumatic stress disorder (PTSD) and a
   See also COMPLICATED GRIEF REACTION; PREPARA-             heightened risk for complicated bereavement con-
TORY GRIEF.                                                  ditions.” Following such traumatic deaths, it is often
                                                             necessary to at least partially resolve the trauma
Casarett, D., J. S. Kutner, and J. Abraham. “Life after      issues before the grief issues can be successfully
   Death: A Practical Approach to Grief and Bereave-         dealt with.
   ment.” Annals of Internal Medicine 134, no. 3 (February
   6, 2001): 208–215.                                                     Grieving the Loss of a Parent
Zerbe, Kathryn J., and Deborah L. Steinberg. “Coming to      Adolescents’ primary concerns relate to them-
   Terms with Grief and Loss: Can Skills for Dealing with    selves—figuring out who they are and where they
   Bereavement Be Learned?” Postgraduate Medicine 108,       belong in their universes (peers, family, society). At
   no. 6 (November 2000): 97–106.                            the same time that they are defining themselves,
                                                             they are loosening the psychological strings of
                                                             parental dependence. Frequently, this involves peri-
adolescents and grief      Adolescence—the period            ods of rebellion and “battles” between teen and par-
between puberty and full maturity—is rife with               ents as the teen works through the psychological
change. More commonly referred to as teens, ado-             separation. When the teen suddenly also faces the
lescents are going through physical growth and psy-          physical and permanent loss of a parent, while deal-
chological development—at times still childlike in           ing with the psychological separation, he or she
their actions, at other times displaying adultlike           may feel responsible—as if those thoughts of want-
behavior. Their increasing ability to reason and think       ing to be rid of parental controls somehow con-
abstractly like adults may cause them more suffering         tributed to the parent’s death.
than children, who are somewhat protected by their               According to some experts, loss of a parent dur-
“magical” way of thinking. Because of these con-             ing the early years of adolescence can be especially
flicting emotions and thoughts, adolescents can find           traumatic because the young teen would have been
the grieving process to be confusing and difficult,           more dependent on the parental guidance and
making them especially vulnerable. Death of a friend         authority that has now been stripped away. And
or family member during this time intensifies the             during later teen years, the adolescent may worry
issues already present during adolescence.                   about how the parent’s death will impact his or her
   Because most adolescents consider death to be             career goals.
something that happens to old people and distant                 Even when the parent’s death follows a lingering
from their foreseeable future, they may seem uncar-          illness, it can be a shock to the adolescent. In their
ing and even callous about deaths not close to them.         article about adolescent grief, Christ et al. followed
Then, when someone close to them does die, it                the grieving process of a 14-year-old whose mother
                                                                                         adolescents and grief 9

had died from cancer. The boy was not seeing death           adolescents experience the loss of a sibling after a
for the first time—an infant sister and a grand-             lengthy illness, they may feel guilty for resenting
mother had died earlier— yet he still had problems           the sibling for receiving so much attention from the
dealing with it. “Although he was kept unusually             parents while going through the illness. Adolescents
well informed about his mother’s condition through-          may feel guilty following the death of a classmate if
out the course of her illness, he was nonetheless            they had been unkind to the classmate, or they may
surprised when she actually died.”                           feel jealous if the classmate had received much
                                                             attention due to illness.”
            Adolescent Reactions to Grief                       These reactions to death may be expressed by
Among the feelings an adolescent may experience              smoking, drinking or taking drugs, sexual activity,
following the death of a loved one are: abandonment,         skipping school, classroom disruption, or fighting.
anger, anxiety, betrayal, bewilderment, confusion,           Others may become “hyperresponsible” and try to
depression, disbelief, despair, fear, guilt, helplessness,   ease the family’s burden by taking the place of the
hopelessness, loneliness, neglect, numbness, panic,          missing parent or sibling. Still others will concentrate
rejection, sadness, shame, and shock.                        on trying to remain “normal” so as not to be differ-
    The death of a parent can be experienced as aban-        ent from friends—boys will struggle not to cry; girls
donment and rejection. Barbara Flynn Sidelau                 will be careful to remain “nice” no matter how they
explains in Comprehensive Psychiatric Nursing that           feel. Although adult and adolescent grieving may
“When a parent dies, the parental obligation to              appear to be similar, adult grief is generally a sus-
remain loyal and give affection, support, nurturing,         tained period of intense sadness or anger. Adoles-
and responsible parenting is not fulfilled. These            cents experience those same feelings, but for briefer
unmet obligations are entered into the ledger as             periods. However, the adolescent’s feelings may
accounts owed. Children experience an injustice.             recur between periods of normal activities and even
They may seek retribution and rebalancing of their           throughout their development. Adolescents may
account by searching for the lost parent through the         also experience more than one stage of grief at once.
assumption of a dependent role in their relationships           Kandt offers four reactions to be aware of regard-
with others. Their neediness is insatiable, and their        ing abnormal grieving in adolescents:
dependency can be a burden on significant others.”
    Anger is a frequent and powerful adolescent reac-        1. Chronic grief reactions Grief is prolonged, exces-
tion to death. The teen may have the urge to “punch             sive in duration, and does not come to an appro-
someone out” or to destroy something. Initially,                priate conclusion.
these outbursts will usually be understood by caring         2. Delayed grief reactions Grief reactions are inhib-
parents, who will respond with concern and under-               ited, suppressed, or postponed.
standing. But as time goes by and the angry out-
                                                             3. Exaggerated grief reactions   Grief is excessive and
bursts continue, parents will grow tired of them and
                                                                disabling.
begin to demand cessation, perhaps even punishing
the teen. Without realizing what is happening, this          4. Masked grief reactions The adolescents experi-
loss of understanding will cause the anger to become            ence difficult symptoms and behaviors, but they
even more entrenched. Even if the teen begins                   do not attribute these symptoms and behaviors
exhibiting less anger and hostility, the relationship           to their loss.
between adolescent and parent may become more
strained and distant. Often this happens when the                     Helping the Grieving Adolescent
parent is also grieving and thus unable to see and           According to Cunningham, the needs of the griev-
understand what the adolescent is feeling. If the two        ing adolescent have long been overlooked, with
cannot resolve the issue of grief, the parent-child          many grief recovery programs concentrating on
relationship may suffer serious damage.                      support for younger children and adults. Some of
    Adolescents may also feel guilty. Citing exam-           the reason for this may be in the mixed messages
ples from a number of studies, Byrne writes, “If             often coming from the teens themselves. “They tell
10 adolescents and grief

us that they need and expect our help in providing            Adolescents dealing with a loss can feel espe-
them with food and a nurturing environment but            cially alone and unsupported during school holiday
also tell us, on the other hand, that they can run        breaks, because they don’t have the usual network
their lives on their own. Because people do not           of teachers and classmates. Involving them in holi-
always know how to respond to teens, they fre-            day plans, listening more attentively to them, and
quently back off, resulting in a teen who is left to      encouraging them to contact school friends may
grieve alone or with very limited support.”               help them feel less lonely.
    Part of the reason given for adolescents being left       When helping teens deal with feelings of anger,
behind during grief assistance is the double-             experts suggest encouraging them to release their
whammy of death and adolescence. According to             physical energy by expressing their anger in ways
Kandt, society is not always comfortable with ado-        that will not harm themselves or others. Cunning-
lescents and the topic of death and grieving. When        ham suggests screaming into a pillow, pounding a
death and adolescence are combined, most people           mattress, ripping tissues out of a box until it is empty,
are not prepared to deal with these two topics. Sim-      or throwing ice cubes at a wall or nearby tree.
ilarly, according to Byrne, “After the death of an            Among the suggestions Cunningham offers for
adolescent, society often focuses on the bereaved         helping adolescents cope with the loss of a loved
parents and not surviving adolescents. Funerals,          one are: encouraging them to talk about why the
social support, and discussions of death are usually      person was special to them, suggesting they write
geared toward the adults.”                                letters to the deceased as a way of saying goodbye,
    Grief counselors suggest that adolescents will        making a collage of words and pictures that remind
heal if they are allowed to express their emotions        them of the deceased, and generally listening when-
and explore their feelings. Because they may pre-         ever they appear ready to talk about any dreams or
tend everything is okay, they likely will need to be      thoughts they are having about death in general
told and shown that it is all right for them to grieve.   and about the deceased in particular.
Just as they are at a point when they are moving              In their study comparing suburban and urban
away from their families emotionally, facing the          adolescents’ experiences of grieving, Morin and
death of a loved one will be tugging at them to           Welsh write, “The most helpful coping strategy men-
revert to more child-like dependence and support.         tioned by the suburban adolescents was a reminder
So they need to be assured that they will not lose        that time would help. Surprisingly, 36 percent of the
any of their hard-won independence if they do             urban youth responded that the most helpful com-
indeed accept—or even seek out—support from               ments were reminders to go to school and get an
other adults in the family.                               education. Perhaps this was related to the height-
    According to Sidney Zisook, professor of psychi-      ened level of violence experienced by the urban
atry at the University of California, San Diego, shar-    youth in this study. Education may be viewed as a
ing timely and accurate information about the             means of escape from the violence in their lives.”
family member’s illness or circumstances surround-        Both groups of adolescents advised adults to talk and
ing an accident is crucial to preventing adult depres-    listen to youth who are coping with death and grief.
sion. “Young people need to ask questions and have            Peers can be very important to grieving adoles-
an adult answer and explain whatever they need to         cents who can go to them for support without hav-
know. They should be given the opportunity to             ing to regress to what seems to them a childlike
attend or even participate in the funeral. They need      state when they get support from parents. Some
to be reassured about the continuing security within      bereavement counselors believe that all adolescents
the family.”                                              need a grief support group of peers within three to
    Hospice Foundation of America adds that adoles-       six months of their loss. According to Byrne, in
cents need to make their own choices about attend-        addition to providing opportunity for grieving teens
ing funerals. “They should decide how they wish to        to “vent and discuss their fears and anxieties,” group
participate in funerals or other services. Adults must    support allows them to explore ways of coping, as
provide information, options and support.”                well as to see that they are not alone in their grief.
                                                                                       advance care planning 11

   Drawing from a number of family studies, Christ         Christ, Grace H., Karolynn Siegel, and Adolph E. Christ.
et al. offer several strategies health professionals         “Adolescent Grief: It Never Really Hit Me . . . Until It
and surviving parents can follow when helping ado-           Actually Happened.” JAMA 288, no. 21 (December 4,
lescents deal with the death of a parent, among              2002): 1269–1278.
them:                                                      Cunningham, Linda. “Grief and the Adolescent,” TAG:
                                                             Teen Age Grief Inc. Available online. URL: http://
• Recognize the adolescent’s expressions of grief.           www.thevine.net/~tag/grief.html. Downloaded March
                                                             3, 2003.
• Educate the adolescent about the grief process.
                                                           Haber, Judith, et al. Comprehensive Psychiatric Nursing, Third
• Provide opportunities for grieving as well as for          Edition. New York: McGraw-Hill, 1987.
  pleasurable remembrance of the parent.                   Kandt, Victoria E. “Adolescent Bereavement: Turning a
• Create enjoyable experiences with the family.              Fragile Time into Acceptance and Peace.” School Coun-
• Support the adolescent’s participation in altruis-         selor 41, no. 3 (January 1994): 203–211.
  tic activities to combat feelings of helplessness.       Morin, Suzanne M., and Lesley A. Welsh. “Adolescents’
                                                             Perceptions and Experiences of Death and Grieving.”
• Draw on support provided by the adolescent’s               Adolescence 31, no. 123 (Fall 1996): 585–595.
  peer group and on services provided by schools,          Rask, K., M. Kaunonen, and M. Paunonen-Ilmonen.
  religious organizations, and agencies.                     “Adolescent Coping with Grief after the Death of a
                                                             Loved One.” International Journal of Nursing Practice 8,
           What Doesn’t Help Adolescents                     no. 3 (June 2002): 137–142.
                  Who Are Grieving
In a Finnish self-report study, adolescents reported
that fear of death, a sense of loneliness, and intru-      advance care plan document          An advance direc-
sive thoughts were factors that hindered their cop-        tive form on which competent adults check off what
ing with grief. Some respondents felt that parents or      level of care they would want in several medical
friends were an additional burden on them. When            end-of-life scenarios. On this legal form, people can
adolescents feel that others are “watching” them,          specify the types of life support systems they do and
they often become self-conscious and embarrassed,          do not want. Kahn gives this as a scenario: “For
so in order to not appear different from their peers,      example, one man may say he will not tolerate
they will hide their grief.                                being tube-fed when he can no longer keep food
    Morin and Welsh report the least helpful com-          down in the normal way, while another will want
ments expressed to adolescents during grieving to be       nutrition provided but not assistance in breathing.
“It was their time” and “You’ll get over it,” for sub-     This permits a physician to omit heroic treatment
urban teens; “I don’t care” and “Get out of my face,”      efforts without civil or criminal liability.” In Florida,
for urban teens—an indicator, they said, of the envi-      PROJECT GRACE created an advance care plan doc-
ronmental differences reported in their study.             ument that conforms to Florida laws and is used by
    Another unhelpful comment often expressed to           physicians and hospitals throughout the state. For
teens who are grieving a death involving a roman-          the full document see Appendix I.
tic relationship is that he or she is “too young to           See also ADVANCE DIRECTIVES.
understand what love is.” Not only do such state-
ments devalue the teen’s grief, they also show a           Kahn, Ada P. “coping with the death of a loved one,” in
total lack of understanding.                                 Stress A to Z. New York: Facts On File, 1998.

“Adolescents Who Are Not Helped with Grief Suffer
   Depression as Adults.” Death Care Business Advisor 7,   advance care planning      Making decisions about
   no. 10 (December 19, 2002).                             medical care is not always easy, especially now that
Byrne, Beverly. “Grief and the Adolescent.” Texas A&M      machines can keep patients alive even when there
   University, July 3, 2002.                               is no hope for recovery. Everyone has the right to
12 advance directives

participate in and plan for his or her own care. But     you.” The entire guide can be downloaded at http://
at some point, a person may become unable to make        www.gov.on.ca/citizenship/seniors/english/advance
those health care decisions. That’s why many med-        care.htm or can be ordered by calling (in Canada)
ical and governmental groups advise people to think      (888) 910–1999.
and talk about their feelings and beliefs with loved
ones long before critical decisions must be made.        Aitken, Jr., Paul V. “Incorporating Advance Care Planning
    By making personal and medical care decisions           into Family Practice.” American Family Physician 59, no.
ahead of time, before physical injury or disease or         3 (February 1999): 605–614.
mental deterioration prevents a patient from con-
tributing to those decisions, substitute decision-
makers—both medical and family—are given the             advance directives A generic term for legally
direction they need to later speak on behalf of the      binding instructions to medical personnel as to what
person who is incapable, and to accurately reflect        medical treatment a person wants or does not want
that person’s wishes about medical, accommoda-           to be undertaken in the event that person is unable
tion, and other personal care choices. Advance care      to participate directly in medical decisions, such as
planning helps seniors ensure that their wishes, not     when he or she is unconscious or mentally inca-
someone else’s, will guide decisions about their         pacitated. They are recognized in one form or
future care. As Aitken writes, “Advance care plan-       another by legislative action in all 50 states and the
ning offers the patient the opportunity to have an       District of Columbia. Advance directives cover such
ongoing dialog with his or her relatives and family      decision areas as blood transfusions, cardiopul-
physician regarding choices for care at the end of       monary resuscitation (CPR), treatment withdrawal
life. Ultimately, advance care planning is designed to   or prolonging, and organ donation. They may take
clarify the patient’s questions, fears and values, and   several forms, the most common of which are LIV-
thus improve the patient’s well-being by reducing        ING WILLs, DURABLE POWER OF ATTORNEY, and DO-NOT-
the frequency and magnitude of overtreatment and         RESUSCITATE ORDERS. Most often, advance directives
undertreatment as defined by the patient.”                are written, but oral instructions may be as legally
    Many state and provincial governments, as well       binding in some states, especially where witnesses
as various medical groups, in recent years have          are present. Advance directives are not mandatory;
begun to offer information on advance care plan-         they are the choice of the person involved. An
ning. For example, in 1992 the Foundation for            advance directive does not take effect until the per-
Healthy Communities, founded by the New Hamp-            son who made it becomes incapacitated, and it may
shire Hospital Association, began offering The           be changed at any time by the person who made it.
Advance Care Planning Guide. It is available for down-   If a person becomes unable to participate in medical
load at http://www.healthynh.com/downloads/              decisions, and he or she has no advance directives,
endoflife.pdf, or a hard copy of the guide in English,    the doctor or other health provider will consult with
French, or Spanish is available for $1 per copy          family members, close friends, or a hospital physi-
from Foundation for Healthy Communities, ACP             cian, depending on state law.
Guide Request, 125 Airport Road, Concord, NH                 Under the PATIENT SELF-DETERMINATION ACT
03301. Braille or audio versions of the guide are        (PSDA) of 1991, any health care facility (hospital,
also available.                                          skilled nursing facility, home health agency, hospice
    In Canada, the Ontario government in 1999            program, HMO) receiving Medicare or Medicaid
issued a Guide to Advance Care Planning to help sen-     funding from the federal government must ask each
iors and persons with dementia in Ontario become         incoming patient (or the responsible family person)
more aware of the benefits of advance care plan-          if the patient has already enabled any advance direc-
ning and their rights in this area. Explaining its       tives; if so, they must be documented in the patient’s
purpose, the introduction states that advance plan-      record. If any provisions of the patient’s previously
ning is “about giving someone you trust the infor-       established advance directives violate the policies of
mation and authority to act on your wishes for           the facility, the patient must be informed that some
                                                                                         advance directives 13

stipulations of the advance directives will not be        choosing someone to help make end-of-life deci-
honored. In addition, facilities must maintain writ-      sions is the most important thing to do first. A good
ten policies and procedures guaranteeing that every       choice is someone who shares the same values, and
adult receiving medical care be given written infor-      who could not benefit from the death.
mation concerning advance directives.                        Although retaining a lawyer to draw up advance
   In a study to assess the prevalence of advance         directives may be advisable, it is not required. Most
directives among nursing home residents before and        states provide forms to follow, but using them is usu-
after passage of the PSDA, Bradley et al. found that      ally optional. Changes in language may be made to
35 percent of the residents in the post-PSDA group        better meet the person’s needs. Computer legal soft-
had an advance directive documented in the med-           ware packages often include advance directive forms,
ical record, compared to 5 percent prior to imple-        but before using these one must be sure that any
mentation of the PSDA. Residents admitted to the          state requirements are met, especially in the area of
nursing home from hospitals (vs. from their homes         witnessing signatures. Each state regulates the use of
or other sources), residents with more education,         advance directives differently. Advance directives
and residents paying privately for nursing home           may be changed or canceled at any time, as long as
care (vs. using Medicare or Medicaid benefits) were        the person is considered of sound mind to do so.
more likely to have documented advance directives.           Usually considered an “old people’s” document,
Residents less than 75 years old were less likely than    and thus given attention only when a family mem-
older residents to have completed a directive. The        ber approaches advanced age, advance directives
most common reason given for completing an                are equally important for the young. Health care
advance directive was experience with the pro-            workers suggest that anyone 18 or older consider
longed death of a friend or family member. Most           writing his or her own advance directives because
residents with advance directives had completed           an accident or sudden illness can impair a young
them more than six months before the nursing              person as well. Sabatino writes, “The stakes are
home admission. Yet experts say that despite pas-         actually higher for younger persons in that, if
sage of the PSDA, only 15 percent of people gener-        tragedy strikes, they might be kept alive for decades
ally have actually completed advance directives.          in a condition they would not want.”
   Not everyone is sold on advance directives as the         Partnership for Caring provides free state-specific
best way to handle end-of-life decisions, however.        advance directive documents, for all 50 states and
Too often, some doctors and ethicists say, the            the District of Columbia, and instructions that
instructions given in these directives appear too         can be opened as PDF (Portable Document For-
ambiguous or leave too much open to interpreta-           mat) files, at http://www.partnershipforcaring.org/
tion. Plus, in today’s medical world of increasingly      Advance/documents_set.html.
more sophisticated technology, directives prepared           See also ADVANCE CARE PLAN DOCUMENT; ADVANCE
even a few years ago do not cover the current range       CARE PLANNING; QUINLAN, KAREN ANN.
of possibilities. They warn that with the increasing
complexity of end-of-life decisions, it may be better     Bradley, Elizabeth H., Terrie Wetle, Sarah M. Horwitz. “The
to designate a HEALTH CARE PROXY. Researchers have           Patient Self-Determination Act and Advance Directive
found that, even when completed, advance direc-              Completion in Nursing Homes.” Archives of Family Med-
tives do not seem to have an impact on well-being,           icine 7, no. 5 (September/October 1998): 417–423.
health status, medical costs, or clinical treatments to   Sabatino, Charles P. “10 Legal Myths about Advance Med-
any significant degree.                                       ical Directives.” ABA Commission on Legal Problems of
   Others caution that expressing a person’s wish is         the Elderly, American Bar Association, Washington,
one thing, but carrying it out can be a different mat-       D.C. Available online. URL: http://pws.prserv.net/
ter. The success of a person’s advance directives            yavapai/Hemlock/10%20Myths.html. Downloaded
depends foremost on talking about what a person              September 12, 2002.
wants, then finding someone who will honor those           “Sample Advance Directive Form.” American Family Physi-
wishes. Some health care experts suggest that                cian 59, no. 3 (February 1999): 617–620.
14 African Americans and death

African Americans and death Culture helps                 crete examples of medical system abuse have made
shape our beliefs and thoughts about death and            African Americans more likely to advocate for all
dying. From its roots in Africa and the Caribbean         means necessary to prolong life. Fear of giving oth-
through injustices endured in America, black cul-         ers the power to take life-threatening actions is due
ture has greatly influenced attitudes and customs in       in part to both historical and structural factors from
the African-American community.                           slavery, Jim Crow laws, and continued feelings of
    Thomas studied medical literature in order to         powerlessness due to poverty and discrimination.”
provide insight into how death, dying, grief, and         That this historical denial of access to health care
loss are viewed by African Americans. Among her           and past abuses in medical research contribute to a
findings: African Americans with AIDS were less            general mistrust of the health care system was also
likely to communicate their end-of-life issues to         suggested by the Project on Death in America as
their physicians than whites. African Americans           likely reasons for the under-usage of palliative and
underutilize hospice for a variety of structural rea-     hospice services by African Americans.
sons, including economics, lack of knowledge, and            Investigators from the Albert Einstein Healthcare
mistrust of the system; but also because they place       Network in Philadelphia echo these findings, report-
more value on curative versus palliative care.            ing that only 8 percent of the African Americans in
    A study by Reese et al. found that African Amer-      their study had a durable power of attorney (com-
icans do not plan for death in the sense of advance       pared to 34 percent of white patients), and only 11
directives and living wills. Rather, they tend to uti-    percent of the African Americans had a living will
lize home remedies before formal systems and              (compared to 41 percent of white patients).
believe that church and family, as opposed to formal         Also, more African-American than white patients
providers, should provide service at the terminal         desired the use of life-sustaining measures, such as
stage. When caring for the terminally ill, they con-      cardiopulmonary resuscitation (CPR) and tube feed-
centrate on living and prolonging life, rather than       ing. Other researchers have also reported that, as a
helping people die comfortably. Those participating       group, blacks have been shown to prefer lifesaving
in the study stated that many African Americans           interventions even when such therapies could be
would rather pray for a miracle than accept termi-        deemed physiologically or medically futile.
nality. They also explained that acceptance of termi-
nality in this culture, while everyone around the                      Superstitions and Traditions
patient is praying for a miracle, would be seen as a      Many of the African-American death-related tradi-
lack of faith. Finally, they reported a belief that God   tions stem from their long history of spirituality. In
determines whether you live or die, not medical           fact, death is not considered the final act as it is in
treatment or the lack of it.                              other cultures; it is more usually looked at as a mere
    Because of such cultural beliefs, there can be a      passage from life on Earth to life in the hereafter.
disconnect between health care agencies trying to         Crawley explains, “We speak of someone who has
help by offering the terminally ill nursing home          died as having ‘passed on,’ suggesting that their
assistance and hospice, and African-American fam-         death was not their final state. It is a notion of the
ilies unwilling to even consider such care away from      immortal soul carrying on its journey of life after
their homes. The Project on Death in America Newslet-     death.”
ter reported in 2002 that African Americans use rel-         Adding to this, Ronald Barrett, an expert on
atively few palliative and hospice services, even         African-American funerary practices, says the term
when they have full access.                               “transition” is traditionally used by blacks to refer to
    Thomas found limited studies concerning the           the dying. “Only rarely would people say ‘the per-
role of culture and end-of-life issues, but did dis-      son died.’ Saying ‘the person transitioned’ means he
cover that “African Americans are less likely to          or she has ‘gone to the next life’ and implies that the
agree to terminating life supports or donating            person has not left us; but simply changed form.
organs because of a historical mistrust of health care    They are no longer physically present, and they’ve
systems. The Tuskegee experiment and other con-           spiritually ‘passed’ into the afterlife.”
                                                                              African Americans and death 15

    Along with this traditional “passing” is the belief      at night by torchlight so as not to stop work during
that life is a circle. Barrett explains that the circle is   the day. Michael Trinkley of South Carolina’s her-
commonly used in African art to represent the con-           itage preservation organization, Chicora Foundation,
tinuance of life. “It is a common belief among blacks        writes, “While owners seem to have had little inter-
today, regardless of where they are in the world,            est in the burials of their slaves, the African Ameri-
that when someone dies, a baby will be born.”                cans seem to have had even less interest in having
    But the journey from here to there is not to be          whites present during this most solemn event. Bur-
without suffering, according to scholars. For many           ial provided an opportunity to provide dignity that
blacks, there’s almost an acceptance, if not a glorifica-     was denied during life and African American beliefs
tion of suffering as a good thing—of even being noble.       held that the dead would be returning to Africa—
Barrett describes discussions at funerals about how          and to a far better life.”
the deceased “fought the good fight, and fought with-
out the assistance of pain medication, just white-                          Leading Causes of Death
knuckled it. There is somewhat of a glorification of          According to the National Center for Health Statistics
that as being somehow a better way to go than peo-           (NCHS), in the year 2000, the 10 leading causes of
ple who have been medicated and thereby have cho-            death for non-Hispanic African Americans, all ages
sen a ‘softer’ way.” Some blacks consider the suffering      and both sexes, were: (1) heart disease, (2) cancer,
necessary during the critical moment of transition.          (3) stroke-related disease, (4) accidents, (5) diabetes,
    Among the superstitions and traditions related to        (6) homicide, (7) HIV, (8) chronic low respiratory
this belief of passing into another world, is the place-     disease, (9) kidney disease, (10) influenza and pneu-
ment of personal items in caskets to provide for the         monia. For a table of the 10 leading causes of death
needs of the deceased in their journey; and in some          by various population groups, see Appendix III.
families, coins are placed in the deceased’s hands,             During the eight-year period between 1990 and
possibly as his or her contribution to the community         1998, there was a decline in the rate of heart-disease
of the ancestors, or as a token for admittance to the        death, the nation’s number one killer, of 11 percent
spirit world. Other traditional African-American             for African Americans.
beliefs include placing coins on or around the grave            The U.S. Centers for Disease Control reported
site, never placing the body directly on the ground,         that through December 1998, 108,874 African-
not burying the dead on a rainy day, and burying the         American males and 32,733 African-American
dead with the feet facing east.                              females died of AIDS-related causes.
    Even though African Americans greatly miss and              According to the National Women’s Health
mourn the dead, the very fact that the deceased              Information Center, the four leading causes of death
will be passing on to a better world makes the               among African American women are, in order of
mourning process a contradiction of grieving and             prevalence, heart disease; cancer; cerebrovascular
celebration. It is a time to rejoice because the             disease, including stroke; and diabetes. These women
deceased no longer has to endure the trials and              have higher mortality rates from a number of dis-
tribulations of this earthly world.                          eases—including heart disease, stroke, and most
    Thus, the mourning is a highly emotional event.          cancers—than Caucasian women.
Typically, families and friends travel great distances          Several health disparity studies have reported
to attend the traditional wake and funeral. Great            higher death rates for African Americans:
amounts of food are prepared by the family and by
neighbors to offer the gathering mourners.                   • African Americans have a higher age-adjusted
                                                               death rate for all of the 15 leading causes of death
                   Slave Burials                               except for suicide and emphysema.
Very few accounts of slave burials were included in          • Cancer death rates are 144 percent higher for
southern histories. Of the few that have survived,             African-American males than white males and
most were recounted by freed slaves and a very few             123 percent higher for African-American females
in plantation owners’ diaries. Slave burials were held         than white females.
16 after-death communication

• Breast cancer age-adjusted death rates are 26.2                deceased: (1) sensing or feeling that someone is
  per 100,000 for African-American women com-                    nearby; (2) hearing a voice, usually by telepathy;
  pared to 19.3 per 100,000 for white women.                     (3) feeling the deceased’s touch, either via a hand or
                                                                 a hug; (4) smelling the deceased’s favorite fragrance;
Between 1999 and 2000 life expectancy increased                  (5) seeing the deceased, either partially, such as
for both males and females in the black population,              head and shoulders, or the entire body; (6) seeing a
increasing by 0.4 years for black males (from 67.8 to            vision of the deceased in a “picture”; (7) “twilight”
68.2) and by 0.2 years for black females (from 74.7              emergences while drifting off to sleep or upon
to 74.9).                                                        awakening or while praying; (8) while sleeping, but
                                                                 more real than dreams; (9) out-of-body experience
Barrett, Ronald K., and Karen S. Heller. “Death and Dying        while asleep or meditating; (10) telephone calls,
   in the Black Experience.” Journal of Palliative Medicine 5,   sometimes while asleep; (11) physical signs, such as
   no. 5 (October 2002): 793–799.                                lamps blinking on or off, televisions or stereos being
Crawley, LaVera M. “Palliative Care in African-American          turned on, pictures moved; and (12) symbols, when
   Communities.” Journal of Palliative Medicine 5, no. 5         asking a Higher Power or the deceased loved one for
   (October 2002): 775–779.                                      a sign that he or she still exists. Such symbols may
Phipps, E., et al. “Approaching the End of Life: Attitudes,      occur in nature or inanimate objects.
   Preferences, and Behaviors of African-American and               The After Death Communication Research Foun-
   White Patients and Their Family Caregivers.” Journal of       dation, which tracks ADC experiences on its
   Clinical Oncology 21, no. 3 (February 1, 2003): 549–554.      www.adcrf.org Web site, says that 19 percent of the
Reese, D. J., et al. “Hospice Access and Use by African          ADC occurrences reported to them occurred within
   Americans: Addressing Cultural and Institutional Bar-         24 hours of the deaths, with 76 percent of these
   riers through Participatory Action Research.” Social          occurrences between blood relatives and only 14
   Work 44, no. 6 (November 1999): 549–559.                      percent between significant others.
Thomas, Norma D. “The Importance of Culture Through-                According to LaGrand, after-death communication
   out All of Life and Beyond.” Holistic Nursing Practice 15,    is not new; The Roman philosopher Cicero (B.C.E.
   no. 2 (January 2001): 40–46.                                  106–43) wrote essays on ADC called “On Divination.”
                                                                 And the English scholar Robert Burton (1577–1640)
                                                                 described ADC incidences during his lifetime.
after-death communication (ADC)           The term                  But not everyone believes such after-death com-
coined by researchers Bill and Judy Guggenheim to                municating is actually the deceased making con-
describe a spiritual experience that occurs when                 tact. Skeptics credit supposed ADCs as more likely to
someone is contacted directly and spontaneously                  be twilight-state illusions, exaggeration, fabrication,
by a deceased relative or friend, without the use of             false memory, magical thinking, or an escape from
psychics, mediums, hypnotists, or devices. Those                 the true reality of the finality of death.
who have experienced ADCs argue that they offer
dramatic evidence of life after death. As many as                Devers, E., and K. M. Robinson. “The Making of a
two in five Americans have had one or more after-                    Grounded Theory: After Death Communication.”
death communication experiences, according to                       Death Studies 26, no. 3 (April 2002): 241–253.
some estimates. In other parts of the world the per-             Guggenheim, Bill, and Judy Guggenheim. Hello from
centage is even higher.                                             Heaven! New York: Bantam Books, 1999.
    In 1988 the Guggenheims began interviewing                   LaGrand, Louis. After-Death Communication: Final Farewells.
people throughout the United States and Canada                      St. Paul, Minn.: Llewellyn Publications, 1997.
about their ADC experiences, and in the process                  ———. Messages and Miracles: Extraordinary Experiences of the
collected more than 3,300 firsthand accounts from                    Bereaved. St. Paul, Minn.: Llewellyn Publications, 1999.
people who believed they had been contacted by a                 Martin, Joel, and Patricia Romanowski. Love beyond Life:
loved one who had died. From their research, they                   The Healing Power of After-Death Communications. New
list 12 most frequent forms of contact by the                       York: Bantam Books, 1998.
                                                                                                      afterlife 17

afterlife A life or existence believed to follow death.     Radio Show about the afterlife and paradise. “The
Results from numerous surveys have shown that as            promise of an afterlife in paradise has apparently
many as 82 percent of Americans believe in an after-        helped to motivate many Palestinian suicide
life. In fact, the number has grown in recent years,        bombers and at least some of the hijackers on the
according to 15 different surveys conducted between         planes that hit the World Trade Center. Mohamed
1973 and 1994, which showed that, over the century,         Atta, the leader of the hijackers, left this message for
belief in an afterlife among Catholics has grown from       some of his fellow terrorists: ‘You will be entering
65 percent to 84 percent; among Jews, the number            paradise. You will be entering the happiest life.’ In
has risen from 22 percent to 40 percent; while among        terrorist training camps, those recruited for suicide
those with no religious affiliation the number has           duty are often told that in the afterlife, virgins will
increased from 31 percent to 50 percent.                    be awaiting them.”
    In those religions and cultures where the belief in        Although there is no reliable, empirical, scientific
an afterlife is strong, acceptance of death can be          evidence for the afterlife, the belief endures. Why?
easier on the bereaved. For example, even though            Canadian secular humanist Derek Watters answers,
Hindus and Buddhists feel the loss of their loved           “Because it satisfies two emotional needs, and pro-
one or friend, they are confident in the dying per-          vides plenty of leverage for religious authorities.
son’s afterlife. They believe that a person is contin-      The Egyptian pharaohs typify one emotional need—
uously reborn to a new life until the person’s spirit       that of immature selfishness; i.e. ‘One life is just
reaches the point of enlightenment and all know-            not good enough for me; I want and deserve more.’
ing. Many Christians accept that there is an afterlife      A more charitable use of the belief is to console
to their present existence, and Christian religions         those in grief. Thinking that a deceased loved one
teach hope for the afterlife. It is based on the belief     has simply gone to a better place may alleviate one’s
that there is one lifetime and that after death the         grief. To a believer, religious authorities are the gate-
good shall exist with God forever.                          keepers to the afterlife. Clerics use this power to
    The afterlife plays an especially important role for    manipulate the behavior of their followers.”
African Americans, according to Barrett:                       But University of Arkansas psychologist Jesse
                                                            Bering suggests that while afterlife beliefs may be
   The belief in an afterlife is a common and funda-        culturally driven in their variety and nature, their
   mental aspect of death and dying in the black expe-      origin lies in our unique biology. He explains that
   rience. But they also believe that the dead are not      human beings represent the only species to have
   in a distant heaven, but rather still among us.          developed a “theory of mind”—the comprehension
   Blacks generally believe that in times of crisis or      that, not only oneself, but also other individuals
   need, and sometimes in times of joy, departed loved      have mental and emotional states that drive their
   ones are smiling down on us, looking out for us,         behavior. This ability to think about the conscious-
   and assisting us. Thus, even though it is stressful to   ness of other people enables human beings to
   have a loved one die, people find comfort in the          engage in complex social interactions. But almost as
   belief that loved ones who may not be physically         a side effect, theory of mind also enables people to
   present are spiritually present.                         consider the consequences of death, not only for
                                                            themselves and other survivors but also for the indi-
But Kahn looks at how belief in an afterlife can have       vidual who died. “Because human beings can think
negative results: “The promise of reward in the after-      about the consciousness of others, they inevitably
life has inspired and comforted many, but has also          come to question whether consciousness persists
been held responsible for making believers passive or       after death.”
accepting of hardships and inequities, which they              Holliday looks at belief in an afterlife as a natu-
could overcome through their own efforts, because           ral part of the evolution of man:
they hope for a better life in the beyond.”
    Strong belief in an afterlife can also have tragic         During the evolution of hominids, the population
results, as experts noted on a 2002 National Public            could be sustained even with an expectation of life
18 afterlife

   at birth of less than 20 years. Under these circum-        Lewis writes that according to the Greek philoso-
   stances very few individuals reached old age. In         pher Plato:
   these hunter-gatherer communities, altruistic
   behavior was encouraged because it increased the            The soul is supposed to journey to a place where
   likelihood of survival, whereas self-interest did not.      there are two openings into the Earth and two into
   An early moral code benefitted the community as              the sky. Judges sit in the middle and send the good
   a whole. As social evolution progressed, the                souls up one of the upper openings and the evil
   chances of survival increased, and for the first time        souls down one of the lower ones. There, the souls
   very elderly individuals appeared. However, the             are either rewarded or punished tenfold for one
   reward for survival to old age was merely decrepi-          thousand years. After that time the souls come
   tude and death. Under these circumstances, new              down or up the other openings and meet together
   incentives became a social necessity, and these             in a meadow to swap experiences. The worst souls
   took the form of a belief in an eternal afterlife.          do not emerge, but are thrown forever into Tar-
   Religion then became the basis for the moral code,          tarus. The rest, after seven days, travel to a place
   and it provided an assurance of continual survival          where the Fates, the Sirens, and all manner of pow-
   after death.                                                ers orchestrate the move into the next life. Each
                                                               soul makes a free choice of the kind of life to be
Belief in an afterlife is certainly not new; it has            born into. Souls that have been enjoying them-
existed throughout the ages. Ancient Egyptians’                selves for the last thousand years tend to be inno-
belief in rebirth after death became the driving               cent and unwary and can choose themselves into
force behind their funeral practices. The Egyptians            trouble by becoming a tyrant. Souls that have been
believed that death was simply a temporary inter-              punished for the last thousand years are more care-
ruption, rather than a complete cessation, of life,            ful and may choose to be an animal.
and that eternal life could be ensured by means
like piety to the gods, preservation of the physical           Also, in Homer, there’s a reference to the Elysian
form through mummification, and the provision               plain, a sort of fabled area at the edge of the world
of statuary and other funerary equipment. Egypt-            where people could go after they die.
ian pharaohs ordered huge pyramids built to guard              Most traditional Native Americans believed in
their valuables and mummified bodies on their trip           some sort of survival after death, although the specific
to the afterlife. Lewis says, “The whole idea of after-     interpretation of the afterlife differed among tribes
life judgment may well have been pioneered by               and locations. For some it followed the white man’s
the Egyptians.”                                             stereotypical “happy hunting ground.” For others, it
    The ancient Slavs of the Ukraine believed in an         was more like a gloomy Hades. And for still others,
afterlife and that the human soul was eternal. It           such as the Eskimos, it took the form of reincarnation.
was the community’s duty to help the deceased live             Judaism does believe in an afterlife, but it is not
comfortably in the next world and attain paradise as        the primary focus of the religion and there is a lot of
quickly as possible. The dead were cremated,                room for personal opinion about the nature of the
buried, or laid on top of the ground and covered by         afterlife, according to Rich:
mounds. Cremation was popular in some regions
because of the belief that fire purified and the               Traditional Judaism firmly believes that death is not
deceased went straight to heaven.                              the end of human existence. However, because
    Zoroastrianism, founded in ancient Persia around           Judaism is primarily focused on life here and now
1000 B.C.E., teaches that for three days after death           rather than on the afterlife, Judaism does not have
the soul remains at the head of its former body. All           much dogma about the afterlife, and leaves a great
of the individual’s good and bad deeds are entered             deal of room for personal opinion. It is possible for
in a sort of accountant’s ledger, recording evil               an Orthodox Jew to believe that the souls of the
actions as debits and good actions as credits. The             righteous dead go to a place similar to the Christian
soul then embarks on a journey to judgment.                    heaven, or that they are reincarnated through
                                                                                                              air tray 19

   many lifetimes, or that they simply wait until the            Rich, Tracey R. “Olam Ha-Ba: The Afterlife,” Judaism 101.
   coming of the messiah, when they will be resur-                  Available Online. URL: http://www.jewfaq.org/
   rected. Likewise, Orthodox Jews can believe that                 olamhaba.htm. Downloaded on March 26, 2003.
   the souls of the wicked are tormented by demons of            Rogers, Alla. “Sworn in Soil: Ukraine’s Living Folk Tradi-
   their own creation, or that wicked souls are simply              tions.” The World & I, April 1, 1995.
   destroyed at death, ceasing to exist.                         San Filippo, R. David. “Acceptance of Death.” Orlando, Fla.:
                                                                    Lutz-San Filippo. Available online. URL: http://www.lutz-
   The notions of resurrection, heaven, and hell have               sanfilippo.com/library/lsfacceptancedeath.html.
been part of Islam since the time of Mohammed.                      Downloaded March 25, 2003.
Both the Koran (Islamic scriptures) and the Hadith               Watter, Derek. “Accepting Heaven as a Myth Can Be a
(the sayings of the Prophet Mohammed) refer to the                  Blessing.” The Hamilton Spectator, March 9, 2002.
afterlife.
   In a poll of nearly 6,000 readers, Omni magazine
found broad agreement on the basic tenet that the                air tray Term applied to the container used to ship
afterlife is a place of light, joy, and bliss. “Geography,       a body via air to another location. An air tray may
income level, religious education, and current reli-             hold the body alone, or the casket and body. An air
gious belief were not strong determining factors for             tray is less costly than shipping the body in a coffin
disagreement; differences in age and sex, however,               because coffins are heavy and airlines charge by the
were. The older the person, the less optimistic he or            pound. A typical air tray for casketed remains could
she was about the hereafter. Older people are more               have a 1 inch by 4 inch pine frame with a one-piece
likely to believe that the afterdeath is not blissful,           .375 inch plywood base, eight 2-inch-wide belt strap
and that there is no communication between the                   handles, and securing straps with removable buck-
afterdeath traveler and the still-living. Women are              les. It would be unfinished and unlined fiberboard.
more likely to believe that the afterdeath is flexible,           Air trays can be custom built, but also come in the
not rigid, and to believe in reincarnation. Men are              following sizes: Adult, Oversized, Youth, Child,
more likely to be persuaded of the existence of life             Infant, and Cherub. A typical charge by a funeral
after death through technological evidence, and are              home for an air tray is $175 to $200, although it can
also more likely to feel that they will be emotionally           range from $75 to $600; the wholesale cost is usu-
alone in the afterdeath.”                                        ally $50 to $75.
                                                                    Airlines usually provide air trays for sale to cus-
Barrett, Ronald K., and Karen S. Heller. “Death and Dying        tomers, or customers may provide their own as
   in the Black Experience.” Journal of Palliative Medicine 5,   long as the construction of the container meets
   no. 5 (October 2002): 793–799.                                the airline and ATA (Air Transportation Associa-
Bering, Jesse M., and David F. Bjorklund. “Intuitive Con-        tion) specifications. US Airways, for example,
   ceptions of Dead Agents’ Minds: The Natural Founda-           offers air trays for the shipping of caskets for $65
   tions of Afterlife Beliefs as Phenomenological                each.
   Boundary.” The Journal of Cognition and Culture 2                Taxes may or may not have to be paid on air
   (November 2002).                                              trays. For example, South Dakota’s Sales Tax Fact
Holliday, R. “Human Aging and the Origins of Religion.”          Sheet says, “Airline air trays are not considered
   Biogerontology 2, no. 1 (2001): 73–77.                        shipping cartons and are subject to the sales tax. If
Kahn, Ada P. “religion,” in Stress A to Z. New York: Facts       the cost of the air tray is charged to the customer,
   On File, 1998.                                                sales tax must be paid. If the air tray is kept by the
Lewis, James R. Encyclopedia of Afterlife Beliefs and Phenom-    receiving funeral home, then use tax must be paid
   ena. Farmington Hills, Mich.: Gale Group, 1994.               by the funeral home on their cost if sales tax was
Menagh, Melanie. “Beyond Death and Dying.” Omni 17,              not previously paid.”
   no. 9 (September 1995): 62–67.                                   The cardboard or plywood container used for
Raphael, Simcha Paull. Jewish Views of the Afterlife. North-     placing a body into a cremation chamber is also
   vale, N.J.: Jason Aronson, 2002.                              sometimes referred to as an air tray.
20 Alaska Natives and death

Alaska Natives and death The term Alaska Native,             pot used during the last illness and other articles
referring to Alaska’s original inhabitants, is used to       such as a man traveling might need, were placed
describe people of Athabascan, Tsimpsian, Tlingit,           outside the grave. The chief mourner did not go
Haida, Eskimo, and Aleut descent, all of whom dif-           out of the house for five days, sat most or all the
fer from each other in ethnic origin, language, and          time on the middle of the house floor, never low-
culture. Thus, their funeral customs and handling of         ered his or her hood, and ate separately from the
death have differed over time.                               rest of the people. There was no singing, drum-
   When early explorers first encountered native              ming, hammering, or other loud noise. At the end
Eskimo villages, they were shocked at how little             of the five days, the chief mourner took off all
regard Eskimos appeared to have for human life.              clothes, and put on new and the old ones were car-
Infanticide, for example, was common. Knud Ras-              ried out on the sea ice and thrown away.
mussen, one of the most famous early explorers,
reported that he met one woman who had borne 20            Earth burial was common among the Eskimos, but
children but had killed 10 of them at birth. Female        cave burial took place among the Aleut. A member
babies, he found, were especially liable to be             of the Billings Expedition to Alaska in 1802 speaks
destroyed, and this was permitted simply at the par-       of the Aleutian Islanders embalming their dead:
ents’ discretion, with no social stigma attached to it.
Old people also, when they became too feeble to              They embalm the bodies of the men with dried
contribute to the family, were left out in the snow          moss and grass; bury them in their best attire, in a
to die. So there seemed to be, in this society,              sitting posture, in a strong box, with their darts and
remarkably little respect for life.                          instruments; and decorate the tomb with various
   According to a 1911 encyclopedia entry, some              colored mats, embroidery, and paintings. With
Eskimos left a dead man’s body in his house, and             women, indeed, they use less ceremony. A mother
shut it up, often leaving by his side a dog’s head to        will keep a dead child thus embalmed in their hut
guide him on his last journey, along with his tools          for some months, constantly wiping it dry; and they
and kayak.                                                   bury it when it begins to smell, or when they get
   Stefansson described a variety of burial and              reconciled to parting with it.
mourning customs he encountered among the Eski-
mos. One example:                                          Other early explorers wrote of finding mummified
                                                           remains of whole families in caves of the Aleuts.
   When a man died during the fore or middle part of          Yet entirely different customs were found among
   the day, while yet there was daylight enough for        other Alaska Natives. Miller writes of the Tlingit
   the funeral, he was put away that day; if too late,     nation of southeastern Alaska and northwestern
   the body remained till morning. People slept in the     Canada: “At death, the opposite moiety (matrilineal
   house with the dead if the body could not be            kinship divisions known as Crow or Wolf clans)
   moved before night. The body was completely cov-        took care of the body, wake, and cremation, while
   ered with the dead man’s own sleeping clothes           the mourners gave full expression to their grief in
   while others slept. When the body was carried out       dirges. Burning the body released the soul to leave
   all sleeping clothes and cooking gear was carried       the town through the cemetery and forest before
   out just after the body and laid for a few minutes on   climbing a mountain to go to ‘the other side’.”
   the snow or on top the roof of the alleyway. Only          Today’s funeral rituals differ from the past, as
   a few followed to the grave; the dead person’s hus-     described in “The Funeral Potlatch of the Tlingit
   band or wife sometimes followed, sometimes sat in       Indians”:
   the middle of the house floor with hood up. They
   often wept, but only from real grief. The body was        As European missionaries started placing pressure
   usually dressed in new clothes, with new mittens          on the Natives to change their ways and customs,
   on hands. A knife was sometimes placed in the             the process of dealing with a deceased person
   man’s hand; the food utensils and special cooking         changed. Traditionally, the body of a deceased per-
                                                                                                 algor mortis 21

   son would be cremated at the exact location of            bestseller, first appearing on that list in October
   death, convenient because the Tlingits were con-          1997 and staying atop the list for four straight years.
   tinually moving. However, as trading communities          Oprah Winfrey produced a major television movie
   became established, the Natives began changing            for ABC based on Tuesdays With Morrie that aired in
   from a transient to a settled lifestyle. As well, mis-    December 1999 and starred Jack Lemmon and
   sionaries outlawed cremation and the Tlingits com-        Hank Azaria. A phenomenon in its own right, the
   plied by burying the dead, thus employing a casket,       movie was not only the most-watched on any net-
   like in Western cemeteries. Gradually, Spirit Houses      work for that year, it also earned four Emmy
   were outlawed and replaced by Christian head-             Awards in 2000, including those for best actor
   stones. As Christianity became the dominating reli-       (Lemmon) and best supporting actor (Azaria).
   gion, a priest or minister often replaced the role of
   the Hasha Da Hani, altering the social structure of
   the Tlingits. Also, when a person passed away, spe-       algor mortis     The cooling of the body that follows
   cial objects were placed beside the body to aid the       death. Also called death chill. After the heart stops
   spirit in the Spirit World. It was taboo for anyone to    beating, the body temperature (normally 98.6°F)
   touch these sacred objects. However, the Tlingits         begins to fall at a rate of about 1.5°F per hour until
   were forced to change their custom to compensate          it reaches ambient (surrounding) temperature;
   for non-native people’s lack of understanding and         often this is “room” temperature or about 70°F,
   respect for funeral rituals as European people con-       although it can be the temperature of surrounding
   tinued to steal these precious objects.                   water or dirt.
                                                                 Algor mortis is one several factors used by
  See also AMERICAN INDIAN/ALASKA NATIVE               AND   pathologists to determine the moment when a per-
DEATH, NATIVE AMERICAN GRAVE PROTECTION                AND   son died, and some consider it the most useful sin-
REPATRIATION ACT.                                            gle indicator during the first 24 hours following
                                                             death. Under “normal” conditions and when the
Lester B. Pearson College of the Pacific. “The Funeral Pot-   body cools at a uniform rate, the rate of temperature
   latch of the Tlingit Indians: The Funeral Potlatch Seen   decrease can indeed be an accurate determinant of
   as a Revitalization Movement,” Lester B. Pearson Col-     the time of death. A rule-of-thumb formula that
   lege of the Pacific. Available online. URL: http://       some forensic personnel follow is: 98.6°F rectal tem-
   www.uwc.ca/SOCANT/HanaOnLine.htm. Downloaded              perature divided by 1.5 = approximate number of
   on March 26, 2003.                                        hours since death.
Miller, Jay. “Alaskan Tlingit and Tsimshian.” University         However, a person’s body temperature is not
   of Washington Digital Libraries. Available online.        always 98.6°F—it can reasonably fall within a narrow
   URL: http://content.lib.washington.edu/aipnw/miller1/     range of 96.7°F and 99°F—plus in individual cases,
   miller1.html. Downloaded on March 27, 2003.               the body temperature at time of death may be lower
Stefansson, Vilhjalmur. My Life with the Eskimo. New York:   or higher than the normal range. For example, the
   Macmillan, 1913.                                          body temperature at death may be lower than nor-
                                                             mal due to hypothermia, shock, or congestive heart
                                                             failure; and above the normal range due to heat
Albom, Mitch (1958– ) Author of Tuesdays With                stroke, strychnine poisoning, and some infections.
Morrie, the heartwarming story of Albom’s relation-              Also, several factors can affect the “normal” 1.5°
ship with his college mentor, Morrie Schwartz, who           drop per hour: physical activity of the person
spent the last five months of his life visiting with          immediately preceding death, illness, size of the
Albom every Tuesday, even as the old man was                 body, clothing or coverings that might have insu-
dying slowly from Lou Gehrig’s disease. The results          lated the body, movement and humidity of the sur-
of those visits comprise what Albom has called “an           rounding air, drugs in the body, and other factors.
old man talking to a young man about the meaning                 Several individuals who have studied the effects
of life.” The book was a phenomenal New York Times           of body cooling suggest that the rate of cooling is not
22 All Hallows’ Day/All Hallows’ Eve

constant, but rather more heat is lost during the            lows’ Eve and All Hallows’ Day a more appropriate
first few hours; then, as the body begins to reach            direction. The converted Celtics continued to be fas-
ambient temperature, the rate of heat loss slows.            cinated by their inherited beliefs of the familiar dead
   The use of body temperature estimations to                returning to the world of the living during these
gauge time of death applies only to temperate cli-           days, and it created quite a bit of unease in the
mates. In tropical climates, the drop in body tem-           church. By establishing a day to honor all dead, the
perature after death may be too minimal for this             church hoped to satisfy the people’s interest in
purpose. In some extreme climates, such as central           death and the supernatural.
Australia, the body temperature may even rise after             In today’s celebration of All Souls’ Day, the Mass
death.                                                       of the day is a Requiem, and the clergy recite the
   See also LIVOR MORTIS; RIGOR MORTIS.                      Office of the Dead. In some Catholic countries, it is
                                                             customary to leave lights in the cemeteries on the
                                                             night before All Souls’ Day.
All Hallows’ Day/All Hallows’ Eve In 835, Pope                  See also DAY OF THE DEAD.
Gregory IV moved the celebration for all martyrs
(later, all saints)—All Hallows’ Day—from May 13
to November 1 in order to displace the pagan                 alternative container A body container; some-
Druidic festival of fire that honored Samhain, their          times called a minimum container. According to the
lord of the dead. The church hoped that this holiday         Federal Trade Commission’s FUNERAL RULE, an alter-
would do away with the Vigil of Samhain and the              native container must be an unfinished wooden
other ceremonies and celebrations held October 31            box or other non-metal receptacle or enclosure,
through November 1 (the Celtic New Year). The                without ornamentation or a fixed interior lining,
night before All Hallows’ Day became known as                which is designed for the encasement of human
All Hallows’ Even or “holy evening.” Eventually, the         remains and which is made of fiberboard, pressed-
name was shortened to the current Hallowe’en, or             wood, composition materials (with or without an
more commonly Halloween.                                     outside covering), or like materials. Alternative con-
   See also ALL SAINTS’ DAY.                                 tainers are generally lower in cost than caskets.
                                                             Funeral homes offering direct cremations must
                                                             make an alternative container available and inform
All Saints’ Day    November 1—a day incorporated             consumers that such containers are available for
into the early Christian calendar because the year           direct cremations. The Funeral Rule also prohibits
was not long enough to dedicate a day to each saint          crematories from requiring that a casket be pur-
of the Catholic Church. Some accounts say it was             chased for direct cremation. However, the rule
especially instituted to honor saints who had died           allows crematories to set standards for the kind of
without their sanctity being recognized. The day             alternative containers that they will accept. For
was originally referred to as All Hallows’ Day, Hal-         example, a crematory might stipulate that it will
lowmas, Hallowmass, or Allhallowmass—meaning                 accept only rigid containers.
sanctified or saintly; thus, the holy day has come to
be known as All Saints’ Day.
                                                             alternative funerals     Until recently, most Ameri-
                                                             cans followed similar customs and rituals when
All Souls’ Day November 2 (or November 3 if the              planning and selecting the funerals and final resting
second is on a Sunday)—a day set aside in the 10th           places of their loved ones. Typically, a clergyman
century by the Catholic Church to recognize and              officiated, using traditional prayers and music, and a
pray for the souls of all the faithful departed still suf-   funeral home embalmed the body, placed it in a cof-
fering in purgatory. According to scholars, the real         fin, and buried it in the ground. Today, however, it
reason for establishing All Souls’ Day was to give           is not uncommon for the deceased to preplan “dif-
the pagan traditions persistently clinging to All Hal-       ferent” arrangements from the traditional services,
                                                                            American Hospice Foundation 23

or for the families to make the service more reflec-         (AAHPM) is an organization of physicians and other
tive of the deceased’s personality and interests while      medical professionals dedicated to the advancement
alive. Alternative funeral services permit families to      of hospice/palliative medicine, its practice, research,
design the service to exactly match their circum-           and education. The mission of AAHPM is the pre-
stances. Services may range from cremation to cryo-         vention and relief of suffering among patients and
genics to mummification. They may mix and match              families by providing education and clinical practice
rituals from several cultures and religions. They may       standards, fostering research, facilitating personal and
include rock music or poetry readings—even pagan            professional development of its members, and by
rituals. They may be GREEN BURIALS or sea burials.          public policy advocacy. Members receive the AAHPM
Alternative arrangements have evolved along with            Bulletin, a quarterly publication. Contact information:
the growing acceptance in society of alternative
                                                            American Academy of Hospice and Palliative
lifestyles and changing family structures, and they
                                                                Medicine
parallel the aging of the “flower child” generation.
                                                            4700 West Lake Ave.
Some sociologists say the trend is at least partially due
                                                            Glenview, IL 60025–1485
to the traumatic events of recent years, from school
                                                            (847) 375–4712
shootings to terrorism, which have forced Americans
                                                            (877) 734–8671 (fax)
to confront death more intimately. Others say that
                                                            http://www.aahpm.org
after spending most of their lives challenging author-
                                                            e-mail: tmckissack@amctec.com
ity and conformity, aging baby-boomers see their
last moments as a final act of self-expression and
rebellion. In addition to the yearning for self-
                                                            American Academy of Hospice Physicians (AAHP)
expression and the newfound concerns about
                                                            See AMERICAN ACADEMY OF HOSPICE AND PALLIATIVE
death, the prohibitive cost of traditional services
                                                            MEDICINE.
has added impetus to the growth in alternative
funerals. Whereas a traditional coffin and service
might run many thousands of dollars, and even a
                                                            American Hospice Foundation A charitable non-
cremation cuts that only to several thousand, a
                                                            profit corporation, the American Hospice Founda-
more simple, alternative “home” service can cut the
                                                            tion was established in 1993 to raise awareness
costs even further.
                                                            about the needs of dying and grieving Americans.
    Even though alternative funerals are becoming
                                                            Since then, the foundation has conducted outreach
more popular, they are still sometimes difficult to
                                                            campaigns in schools, in the workplace, and among
obtain. Often traditional funeral directors and reli-
                                                            health insurers. The foundation’s primary goal is to
gious authorities are resistant to these changes. But
                                                            increase access to hospice by making Americans
a burgeoning alternative funeral industry is slowly
                                                            aware of hospice availability, affordability, and phi-
gaining ground, as new companies emerge specifi-
                                                            losophy. To this end, the foundation conducts a
cally for offering customized funerals, and as some
                                                            variety of education programs in collaboration with
traditional companies add alternative services to
                                                            local community organizations and national associ-
their offerings.
                                                            ations of professionals who can carry the hospice
                                                            message to their constituents. Contact information:
Langton, James. “Children of ’60s Get the Last Word:
   Alternative Funeral Trend Growing.” The Washington       American Hospice Foundation
   Times, March 20, 2000.                                   2120 L Street NW
                                                            Suite 200
                                                            Washington, DC 20037
American Academy of Hospice and Palliative Med-             (202) 223–0204
icine (AAHPM) Originally organized as the Acad-             (202) 223–0208 (fax)
emy of Hospice Physicians in 1988, the American             http://www.americanhospice.org
Academy of Hospice and Palliative Medicine                  e-mail: ahf@americanhospice.org
24 American Indian/Alaska Native (AI/AN) and death

American Indian/Alaska Native (AI/AN) and death            percent). Other highly AI/AN populated states were
For statistical purposes, the U.S. government and          at 4.3 percent (Alaska), 2.5 percent (New Mexico),
various health agencies group Native Americans             and the lowest was South Dakota at 1.9 percent.
and Alaska Natives into one population segment             Mistakes are less likely to be made if an Indian died
they call American Indian/Alaska Native (AI/AN).           within his or her reservation boundaries or in an
AI/ANs are constituted as 556 federally recognized         IHS facility. The Centers for Disease Control and
tribes. Each tribe belongs to one of seven nations         Prevention (CDC) publication on health statistics
(such as the Navajo or Iroquois); 226 of these tribes      shows the racial misclassifications among American
are in Alaska, while the others are in 34 states in        Indians, overall, is 22 percent. Such miscoding can
the continental United States. Nearly 300 reserva-         affect research funding, which is based on morbid-
tions in the lower 48 states and approximately 500         ity statistics skewed by race.
government units in Alaska serve as homes to the               The Indian Health Service provides health care
tribes.                                                    services to about 60 percent of American Indian and
   But not everyone believes this grouping is such         Alaska Native populations. About three-fifths of the
a good idea. For example, McCabe writes that such          Native American population live off the reservation,
“lumping” into one population group can lead to            and it is estimated that one-half now live in urban
wrong assumptions and inaccurate data:                     areas. In its relatively short history, the Indian Health
                                                           Service has contributed to tremendous improve-
   It is critical to recognize the heterogeneity between   ments in the health status of American Indians and
   and within the 500 to 600 tribal groups, which is       Alaska Natives. Since 1973 infant mortality has
   manifested in the epidemiology of disease and the       decreased by 58 percent, maternal mortality by 68
   cultural values and beliefs of each group. For          percent, pneumonia and influenza mortality by 52
   example, while the overall leading causes of death      percent, tuberculosis mortality by 79 percent, and
   among AI/ANs are diseases of the heart, in the          gastrointestinal mortality by 76 percent.
   Alaska, Navajo and Albuquerque areas they are               However, although significant gains have been
   accidents and adverse effects (Indian Health Service    made, the health status of American Indians and
   [IHS], 1998–1999). One must avoid the tendency          Alaska Natives is not equal to that of the U.S. gen-
   to generalize . . . findings, discussion and recom-      eral population. Poor nutrition, coupled with unsafe
   mendations to all tribal groups and villages.           water supplies and inadequate waste disposal facil-
                                                           ities, has resulted in a greater incidence of illness in
   Smith et al. echo this: “The overall rates of injury    the Indian population. Many reservations and
are misleading because considerable variation exists       Indian communities are located in isolated areas
among tribes. For example, firearm-related death            where impassable roads and a population spread
rates vary six-fold, fire- and burn-related death rates     over many miles create additional challenges to the
seven-fold, and drownings 22-fold among IHS serv-          IHS commitment to provide quality health care.
ice areas. Each tribe is unique in its culture, history,       Thomas writes that “American Indians/Native
language, and sociopolitical circumstances.”               Americans rely on the extended family system,
   Another problem when accumulating AI/AN                 especially for tribal groups who still live on reserva-
death statistics is misidentification. Several studies,     tions. They treat the issue of death and dying in a
including one from the IHS, have found that the            way similar to other American ethnocultural
race of AI/ANs is identified (coded) inconsistently         groups; that is, to speak about death may cause it to
on state death certificates. Staff from hospitals and       happen. Therefore, issues like ADVANCE DIRECTIVES
funeral homes have a tendency to use “personal             often are not discussed.”
observation” plus the deceased’s last name rather
than definitions of race used by the IHS.                               Leading Causes of Death
   According to the IHS study, Texas is ranked at the      According to the 1990 Department of Health and
top for miscoding at a rate of 47.1 percent, followed      Human Services report Healthy People 2000, the six
by Arkansas (43.6 percent) and Oklahoma (26.3              major causes of early death for American Indians
                                                    American Indian/Alaska Native (AI/AN) and death 25

and Alaska Natives are unintentional injuries, cir-          The combined unintentional and intentional
rhosis, homicide, suicide, pneumonia, and compli-        injury mortality rate among the AI/AN population
cations of diabetes. Alcohol and obesity are major       is three times the rate for the general U.S. popula-
risk factors for the American Indian population.         tion. It is estimated that 75 percent of female Native
Alcohol contributes to high rates of motor vehicle       American Indian and Alaska Native homicide vic-
crashes, cirrhosis, suicide, homicide, domestic          tims are killed by someone they know.
abuse, and fetal alcohol syndrome. The increase in           According to the National Women’s Health Infor-
obesity among American Indians, resulting partly         mation Center, the four leading causes of death
from the adoption of a Western diet, has paralleled      among American Indian/Alaska Native women are,
the increase in diabetes, which is 230 percent higher    in order of prevalence, heart disease, cancer, unin-
than in the general population. Obesity is also          tentional injuries, and diabetes. These women have
linked to high blood pressure and stroke, coronary       lower death rates from most major diseases—includ-
heart disease, and some types of cancer. The Indian      ing heart disease, cancer, stroke, and chronic
Health Service, as well as state and local health        obstructive pulmonary disease—than Caucasian
departments, is working with Native American             women. For example, breast cancer death rates for
communities to develop programs that will meet           the American Indian/Alaska Native are lower than
these health challenges. By recognizing and incor-       for Caucasian women. However, their mortality
porating American Indian and Alaska Native tradi-        rates from chronic liver disease and cirrhosis, kidney
tions, culture, and values into community health         disease, suicide, and homicide are higher than those
care programs, health care providers are becoming        of Caucasian women. American Indian/Alaska
more effective in meeting the needs of this very         Native and black Americans report the shortest life
diverse minority.                                        expectancies among American women.
   According to the IHS, the top-five leading causes          In 1999 diseases of the heart accounted for as
of death among AI/ANs between the ages of 55 and         much as 31 percent of all deaths to white females
64 are diseases of the heart, malignant neoplasms,       and as little as 21 percent of all deaths to American
cerebrovascular diseases, diabetes mellitus, and         Indian/Alaska Native females. The third-ranked
pneumonia and influenza. Motor vehicle injuries           killer of females is cerebrovascular diseases (pri-
are the leading cause of death among American            marily strokes). American Indian/Alaska Native
Indians and Alaska Natives ages one to 44, accord-       women provide the only exception to this because
ing to the CDC (1998), with Native Americans             unintentional injuries is their third-ranked killer.
dying in motor vehicle accidents two to three times      Cerebrovascular diseases rank fifth among the
more than other Americans.                               causes of death for American Indian/Alaska Native
   During the eight-year period between 1990 and         women.
1998, there was a decline in the rate of heart-disease       Among women of all races and age categories,
death, the nation’s number one killer, of 8 percent      American Indian females ages 25–44 have the sec-
for AI/ANs.                                              ond highest death rate due to suicide—at 6.5 per
   CDC reports show that through December 1998,          100,000.
877 American Indian/Alaska Native males and 158              Death rates associated with alcoholism are much
American Indians/Alaska Native females had died of       higher among AI/AN women than among women
AIDS-related causes.                                     of all races. For the 1994–96 period, mortality due
   In 1997 American Indians/Alaska Natives ages          to alcoholism among American Indian/Alaska
15 to 19 (of both sexes) had the highest suicide         Native women ages 25–34 years was nearly 21 per
mortality among all racial and ethnic groups, at 20.5    100,000 population, in contrast to the slightly more
deaths per 100,000 population. The suicide rate for      than one per 100,000 rate for women of all races.
American Indian/Alaska Native youths is more than        American Indian/Alaska Native women ages 35–44
twice the rate for white adolescents, and, in contrast   had a mortality rate due to alcoholism of 67 per
to the national pattern, suicide is more likely to       100,000 in 1994–96, nearly 14 times the rate of
occur among younger adolescents than older ones.         U.S. women of all races.
26 American Indians and death

   AI/AN infant mortality rates are 45 percent                 Indian burial mounds remain throughout the coun-
higher than those of whites, and some American                 try; others are interred in simple graves.
Indian communities have infant mortality rates that               The method of disposing of the dead varied
approach twice the national average.                           according to both the tribe and the environment,
   Three times as many American Indians/Alaska                 with INHUMATION being the most widespread. The
Natives, as persons in the general population, die             Huron and the Iroquois allowed the bodies to decay
before reaching the age of 45.                                 upon scaffolds, after which the bones were gathered
   The six leading causes of death in 1995 for eld-            up and deposited with much ceremony in the com-
erly American Indians/Alaska Natives were heart                mon tribal SEPULCHER. The Abenake and Mohawk
disease, cancers, diabetes mellitus, cerebrovascular           natives buried their dead on high elevations because
disorders, pneumonia and influenza, and accidents.              hilltops are closest to the stars, enabling souls to
   According to 1997 IHS data, the life expectancy             leave Earth and enjoy happy reunions with their
for AI/ANs has dramatically increased. Life                    ancestors in the heavens. The Nanticoke and
expectancy for those born between 1972 and 1974                Choctaw scraped the flesh from the bones, which
was 63.5 years, compared to 71.1 years for those               were then wrapped in a bundle, and kept in a box
born between 1992 and 1994.                                    within the dwelling. Some Indians burned their
                                                               dead; some like the Osage buried their dead in a sit-
Leigh, Wilhelmina A., and Maren A. Jimenez. Women of           ting position in a mound of rocks. Tree, scaffold,
   Color Health Data Book. National Institutes of Health.      and cave burial were common on the plains and in
   Available online. URL: http://www.4.od.nih.gov/             the mountains, while cremation was the rule in the
   orwh/wocEnglish2002.pdf. Posted 2002.                       arid regions farther to the west and southwest. In
McCabe, Melvina. “Treating American Indians/Alaskan            the northern areas, the body was commonly
   Native Elders.” Geriatric Times 2, no. 6 (November/         deposited in a canoe raised upon posts.
   December 2001).                                                According to Bruce M. Mitchell and Robert E.
Smith, Richard J., III, Alan J. Dellapenna Jr., and            Salsbury in their Encyclopedia of Multicultural Educa-
   Lawrence R. Berger. “Training Injury Control Practi-        tion (Greenwood Press, 1999), “Navajos feared
   tioners: The Indian Health Service Model.” Uninten-         death and the ceremonies were brief. The deceased
   tional Injuries in Childhood 10, no. 1 (Spring/Summer       were placed in crevices and covered with stones
   2000): 175–188.                                             after the body was bathed and dressed in fine cloth-
Thomas, Norma D. “The Importance of Culture Through-           ing and jewelry. In the Great Basin, burials often
   out All of Life and Beyond.” Holistic Nursing Practice 15   took place in caves, while in California, cremation
   no. 2 (January 2001): 40–46.                                was common. The Hurons held a feast for the dead
                                                               every ten to twelve years.”
                                                                  Jutla Atli writes, “Cherokee people bury their
American Indians and death        “American Indian” is         dead. In ancient times we constructed burial
used to refer to more than 545 federally recognized            mounds and then that practice later gave way to
tribes residing in states other than Alaska. Although          burying the dead in the ground, either in the floor
one of the smallest minorities in the United States,           of the dead person’s house or somewhere nearby.”
American Indians are a very diverse group, repre-                 Post writes, “Native burial customs involved a
senting a variety of cultures and traditions.                  great deal of symbolism. People were buried facing
                                                               the rising sun, sometimes in sitting positions. Elderly
       Burial Customs of American Indians                      natives, sensing death approaching, would leave vil-
American Indians have different burial customs                 lages and climb a hilltop waiting to take their final
according to their distinct tribal identities. Some tribes     breaths while seeking the ‘Spirit of the North.’
placed their dead in canoes and propelled them into            Sometimes local tribes left dead bodies exposed on
waterways or out to sea. Other tribes wrapped their            raised platforms, a practice common to Plains
dead and placed them within branches of trees for a            natives. Later, bones would be buried wrapped in
tree burial. Still others placed them on scaffolds.            elm or birch bark.”
                                                                                               ancestor worship 27

   Indian grave sites found on Long Island show               Americans for Better Care of the Dying
that funeral rites were commonplace. Wick writes,             4200 Wisconsin Avenue NW
“In a few cases, personal belongings were included            Suite 418
in the grave. In others, dogs were killed and placed          Washington, DC 20016
in the grave. In the late 1920s, a construction crew          (202) 895–2660
building a house near Lake Montauk found a                    (202) 966–5410 (fax)
wooden coffin that contained the remains of an                info@abcd-caring.org
adult female and a small dog. Copper pots, glass              http://www.abcd-caring.org/
beads, and pipes were also in the grave. Historians
believe that the dogs were included in graves to
help guide the dead to the next life.”                        anatomical gifts   The donation of all or part of the
                                                              body. BODY DONATION is usually for medical
Atli, Jutla. “Atagahi: Common Misconceptions.” Available      research, and ORGAN AND TISSUE DONATION is for
   online. URL: http://www.geocities.com/tsutla_atli/         transplant. Some families balk at carrying out the
   misconceptions.htm. Downloaded April 5, 2003.              deceased’s request for body or organ donation
Post, Paul. “Development Threatens Native Burial Sites.”      because they fear this will mean body disfigurement
   The Saratogian, November 20, 2002.                         or no public viewing at all. But the National Funeral
Wick, Steve. “A Time to Live, A Time to Die: From Birth to    Directors Association dispels these fears:
   Death, the Indians of Long Island Marked the Passing
   Stages of Life.” Newsday. Available online. URL: http://      Whether the entire body or just the organs are
   www.newsday.com/extras/lihistory/2/hs206a.htm.                donated, medical personnel can usually make
   Downloaded April 16, 2003.                                    arrangements for the body to be present for the
                                                                 funeral. In some instances, if the funeral director
                                                                 knows a body has been donated to a medical
Americans for Better Care of the Dying (ABCD)                    school, he or she will call the school and prepare
Founded in 1997, Americans for Better Care of the                the body according to their directions. The body
Dying (ABCD) is a nonprofit organization dedicated                will then be taken to the school after the funeral.
to ensuring that all Americans can count on good end                 When organs are removed, the funeral director
of life care. The organization’s goals are to: build             can use his or her embalming and restorative art
momentum for reform, explore new methods and                     skills to help return the body to a natural-looking
systems for delivering care, and shape public policy             state for the viewing and funeral. The body can still
through evidence-based understanding. Its efforts are            be buried according to the family’s wishes.
focused on fundamental reforms, such as improved
pain management, better financial reimbursement                   See also UNIFORM ANATOMICAL GIFT ACT.
systems, enhanced continuity of care, support for
family caregivers, and changes in public policy. ABCD
helps other organizations and individuals fix their            ancestor worship The religious worship of ances-
own community care systems and assists health care            tors based on the belief that the spirits of the dead
organizations in implementing rapid-cycle quality             continue to dwell in the natural world and have
improvement methods. “We are committed to ensur-              the power to influence the fortune and fate of the
ing that every person experiences comfort, dignity,           living. This worship is not a religion in and of itself,
and meaning at the end of life, and that every loved          but more an expression of religion that recognizes
one knows that life came to a close in a dignified and         an element beyond human control. Ancestor wor-
meaningful way. By sharing expertise, building col-           ship is at the core of people’s religious practices in
laborative networks and public commitment, ABCD               China, tropical Africa, Malaysia, and Polynesia.
seeks to achieve substantive health care reform               Aspects of this type of worship have been traced to
through improved policy, professional practice, and           the ancient Egyptians and Romans. Various aspects
care reimbursement.” Contact information:                     of it existed among the ancient Hebrews, but their
28 “Angel of Death”

worship was more of a reverence for the dead. The            The offering of gifts and food to ancestors stems in
worship is neither universal nor widespread among            part from early fears. Doctor and Kahn explain,
primitive people.                                            “Dead ancestors, who were worshiped in many
   Spier writes that “The basis of ancestor worship          early cultures as gods or near-gods, were thought to
seems to stem from two principle ideas: (1) that             be easily angered. Gifts and ceremonies were nec-
‘those who have gone before’ have a continual and            essary to sustain their goodwill and decrease hostil-
beneficent interest in the affairs of the living; and         ities the dead were believed to bear toward the
(2) more widespread, uneasiness, fear of the dead,           living.”
with practices to placate them. The later ideas more
often serve as a form of dispensing emotions than of         Doctor, Ronald M., and Ada P. Kahn. “Phasmophobia,” in
worship.”                                                       The Encyclopedia of Phobias, Fears, and Anxieties, Second
   People of Eastern religions often create altars to           Edition. New York: Facts On File, 2000.
their ancestors at which they offer prayers and per-         Hsu, Francis L. K. Under the Ancestors’ Shadow: Chinese Cul-
form ceremonies. The ancestral altars contain                   ture and Personality. New York: Columbia University
ancestor tablets, narrow wood tablets about 12                  Press, 1948.
inches tall that have the names of deceased rela-            Spier, Leslie. “Ancestor Worship.” The Mystica. Available
tives written in gold characters. Incense and other             online. URL: http://www.themystica.com. Down-
offerings are placed before the tablet in honor of              loaded April 6, 2003.
the ancestors.
   In Eastern cultures, ancestor worship may be car-
ried out by such rituals as annual ceremonies and            “Angel of Death”      A derisive nickname given to
offerings, daily lighting of incense, periodic setting       people who have been accused or found guilty of
of a spirit table, regular food offerings, or ritualistic    causing the deaths of many persons. It was applied
recognition of ancestors at weddings. Money, called          to Dr. Josef Mengele, the Nazi officer and physician
“spirit money,” may be offered to the gods of the            who controlled the fate of Auschwitz concentration
underworld to alleviate the ancestor’s suffering.            camp prisoners during World War II, deciding which
   Describing ancestor worship in Chinese culture,           ones were to go to the gas chamber. The nickname
Hsu writes:                                                  has also been used for nurses and doctors accused of
                                                             mercy killings of their elderly or comatose patients.
   Each household has a family shrine. The shrine is            Many religions have the concept of an angel of
   situated in the central portion of the second floor of     death. Often it is personified as the GRIM REAPER.
   the west wing of the home. It is installed on the            Between the ages of five and nine, children tend
   ground floor only when the house is a one-story            to personify death and often associate it with the
   structure. Occasionally the shrine is for ancestors       angel of death.
   only, but more often it houses a number of popular
   gods. Ancestors are represented in such a shrine
   either on a large scroll or on separate tablets. The      angels   In many religious traditions—especially
   scroll is a large sheet of mounted paper containing       Christianity, Judaism, Islam, and Zoroastrianism—
   names, sex, and titles of the ancestors who are (the-     angels are lesser spiritual beings who assist and
   oretically) within wu fu, or five degrees of mourn-        serve God or the gods. Typically, angels are benev-
   ing. The tablets are made of wood, but if there is no     olent beings who act as intermediaries between
   time to have one made, a paper one will be substi-        heaven and Earth. They are most often represented
   tuted. Incense is offered in each burner daily, usually   as human figures having halos and wings. In early
   by a woman of the house. This act is performed            “guidebooks” for living and dying as a Christian,
   every morning just before breakfast. There is no          the death bed scene was frequently depicted with
   offering of food except on occasions of marriage,         devils and angels vying for the soul of the dying
   birth, division of the family, and during the ancestor    person. In the 16th-century woodcut, “The Soul
   festival.                                                 Goes to Heaven,” seven angels have six keys—
                                                                                      anniversary reaction 29

standing for the six works of charity—with which           the grieving person may feel angry that others lived
they open heaven and receive the soul into heaven.         while the loved one died; he or she may question
For Muslims, the soul is escorted by the angel             religious beliefs, and may even accuse family mem-
Gabriel through seven layers of heaven.                    bers or friends of not caring or not understanding.
                                                           Following suicide the anger may be aimed at the
                                                           deceased.
anger     Anger is the second of five stages in the            These feelings of anger and hostility can be equally
acceptance of death by the dying person, as                difficult to accept for the person experiencing them,
described by psychologist ELISABETH KÜBLER-ROSS. It        especially if he or she has been taught that anger is a
is also referred to as the protest or “why me?” stage.     negative emotion to be avoided or smothered.
During this stage the person partially accepts the         Sometimes the grieving person’s anger will be com-
knowledge that he or she is going to die but               pounded by worries that his rage is so overwhelm-
becomes angry at the unfairness of having to die           ing it may lead him to violence or madness.
while other people go on living. During this stage,           But in most cases, rage and anger provide a
the dying person can be difficult to get along with,        cathartic means of expression and of accepting the
creating an especially challenging time for care-          significance of death. At this stage one begins to ask
givers. When Kübler-Ross interviewed patients dur-         questions about the death—who is to blame and
ing her research, she found that the more energetic        what does it mean. By externalizing these ques-
and peppy the nurse, the more anger she provoked           tions, putting the blame on God or doctors, the
in the patient during this phase. By lashing out, the      anger stage helps the person handle the questions
dying patient is expressing anger at not being able to     more easily. Psychiatrists say that persons who ver-
anticipate the freedom, vitality, and purpose repre-       balize their anger or work it out physically (e.g.,
sented by the nurses and others. The anger may             through vigorous exercise or gardening) are less
even be directed at the patient herself in the belief      likely to have COMPLICATED GRIEF REACTIONS.
that this illness is a result of her own wrongdoing—          The death of a sibling, parent, or close relative
a punishment, so to speak. Patients are best served        can especially arouse feelings of anger in children.
during this stage by being allowed and encouraged          They may feel angry with the person who died for
to express their feelings freely. If these feelings can-   causing them so much pain and sorrow or for leav-
not be expressed, the anger may turn inward and            ing them alone. Children are more apt to express
the patient may become extremely depressed. By             their anger openly, especially when they have lost
continuing to remain calm and loving toward the            someone upon whom they depended for love and
patient during these spells of anger, caregivers help      care. Children need to be reassured that they will be
keep the dying from feeling so alone. Kübler-Ross          cared for.
maintained that this stage is not radical, and that if        See also ACCEPTANCE; BARGAINING; DENIAL;
patients are treated with respect and understanding,       DEPRESSION.
their anger will probably fade.
    Anger is also a commonly experienced phase of          Borins, M. “Grief Counseling.” Canadian Family Physician
grief. Once the grieving survivors get past the denial       no. 41 (July 1995): 1207–1211.
stage and accept the fact that the loved one has died
or will soon die, they often next ask, “Why her (or
him)? Why my loved one?” This usually is expressed         anniversary reaction      An increase in the intensity
as anger toward each other for not being able to stop      of the grief response or some emotional reaction at
the death, toward the caring health professionals for      certain times, even after there has been some reso-
not preventing it, or, very often, toward God for          lution to the loss. Cook and Dworkin write, “Certain
allowing or making this happen.                            days or times of the year that have significance (for
    Of all the stages in the grieving process, anger       example, birthdays, holidays, seasons, the date of
can be the most difficult for a friend or family mem-       death) can trigger thoughts of the deceased, and
ber to understand and deal with. During this stage,        some of the earlier pain may return for a short
30 announcing a death

period of time. As long as this response subsides             many newspapers will be a column or page of paid
after the anniversary period, even if it occurs each          death announcements. In some churches and syn-
year, it is a necessary step toward healing. If, on the       agogues, the clergy may deliver a formal notice of
other hand, an old wound is opened and the pain               death. In small communities, the local radio station
shows no evidence of ending, an important unre-               may read death notices.
solved facet of grief may still exist and professional           In some countries, such as Israel, where the high
attention may be warranted.”                                  cost of placing a paid death notice in the newspaper
   Anniversary reactions can also occur following a           has led to some public outcry, death notices are cus-
traumatic event, such as the 9/11 disaster. Emo-              tomarily posted on and near the home of the
tional reactions can occur on the date of the event,          bereaved family, as well as on public bulletin boards.
but can also be triggered by disturbing news reports
about the trauma.
                                                              anticipatory grief     When a death is anticipated
Cook, Alicia Skinner, and Daniel S. Dworkin. Helping the      due to terminal illness, adults commonly report
  Bereaved: Therapeutic Interventions for Children, Adoles-   experiencing grieflike reactions prior to the actual
  cents, and Adults. New York: Basic Books, 1992.             death of a spouse, parent, or child. Anticipatory
                                                              grief has been defined as the total set of cognitive,
                                                              affective, cultural, and social reactions to expected
announcing a death Various religious, legal, and              death felt by the patient and family. Some of the
cultural codes and traditions are observed in                 signs and symptoms of anticipatory grief include:
announcing a death. Informing the immediate next              feelings of guilt, tearfulness, constant changes in
of kin takes precedence over relatives who may be             emotions, anger, depression, feelings of emotional
nearer to the scene of death, and it is a breach of eti-      numbness, anxiety or feelings of fear, changes in
quette not to notify a close relative about a death.          sleeping and eating habits, poor concentration, for-
Traditionally, the announcement of a death occurs             getfulness or poor memory, loneliness, fatigue.
immediately following confirmation by the medical                  Cook and Dworkin explain that anticipatory grief
doctor. With Orthodox Jews, there may be a delay              emanates from the expectation of emotional pain
in announcing a death (especially just before the             and the life changes the loss will bring. “Although it
beginning of the Sabbath) and arrangements for                does not completely prepare a survivor for the emo-
interment have to wait until after the Sabbath.               tional experience of the actual loss, it does allow
    Until fairly recently, telegrams were commonly            time for resolving emotional issues with the
used to announce the death to relatives, close                deceased and preparing for the future. Sudden
friends, attorneys, and business associates. Although         death is particularly difficult to handle since it usu-
still used occasionally today, telegrams have been            ally does not allow this process to take place.”
supplanted by the telephone, mail, fax, and e-mail.               According to Watstein, “Anticipatory grief helps
A more formal way to announce a death to distant              bring eventual closure. By giving us the chance to
relatives and associates is by sending printed cards,         project into the future and see the loss before the
much like wedding announcements, but with a                   fact, we are granted time to be ‘real’ with the dying
black border around the card.                                 person, to say the things we always meant to and,
    In some rural areas, such as the Appalachian              perhaps, to share on a deeper level than previously.”
Mountains, a church bell would toll to the number                 Nussbaum et al. warn that although anticipatory
of the deceased person’s years. Not only would this           grief may make it easier for survivors to pull things
announce a death to the surrounding community,                together after the death, it can affect communica-
but also it would often be a clue as to who had               tion prior to the death and lead to a “social death,”
passed away, unless death was due to an accident.             with people treating the person as if he or she is
    Typically, an OBITUARY notice is published in local       already dead. Family members may even become
newspapers announcing the death and type of serv-             irritated that the death is taking so long. “Anticipa-
ice to be held. Accompanying these obituaries in              tory grief can become a double-edged sword:
                                                                                 Arlington National Cemetery 31

Although it helps secure the well-being of the sur-            anxiety about dying A feeling of unease and
vivor, it ruptures any remaining social bonds                  apprehension when thinking about one’s own
between the dying and surviving family members.                death. Anxiety about dying can be experienced by
Those social bonds are tenuous enough at this point            people at any age, but generally it tends to decrease
and are easily severed.”                                       in late adulthood. Among the causes of such anxi-
   Gilbert addresses the controversy and confusion             ety: Dying is the loss of the world in which one has
that exists around the concept of anticipatory grief:          lived, worked, and loved. There is also anxiety
                                                               about the moment of dying. Or, there can be a fear
   Research on anticipatory grief has been contradic-          of what comes after death. This can vary from a
   tory and problematic. Some studies have found that          vague anxiety about the unknown to a literal,
   the ability to anticipate a loss results in an easier       deathly fear of punishment that may be eternal.
   grief experience. Others have found no relation-            Nossaman writes, “A lot of our anxiety about death
   ship between a period of anticipation and the sever-        has to do with what follows it and the fact that we
   ity of post-death grief. A few studies have found a         are so much in the dark about it. Dying involves
   mid-range “window of opportunity” for better post-          crossing to the other side of the curtain, an experi-
   death grief outcomes. . . . The situation is even           ence which is invisible and unknown.”
   more complex when the process of coping with                   See also DEATH ANXIETY; THANATOPHOBIA.
   anticipated loss in the family is considered. Family
   members may be at any number of points in their             Nossaman, Nicholas. “Reflections on Death.” The New En-
   grieving of the loss. There may, in fact, be family           gland Journal of Homeopathy 9, no. 2 (Fall/Winter 2000).
   members who have not begun to grieve while oth-
   ers have moved to separate themselves, emotion-
   ally, from the person who is dying.                         Arlington National Cemetery A national ceme-
                                                               tery located on the Virginia side of the Potomac
Some researchers report that anticipatory grief                River near Washington, D.C., and under the juris-
rarely occurs. They support this observation by not-           diction of the Department of the Army. Arlington
ing that the periods of acceptance and recovery usu-           Mansion (originally the Custis-Lee Mansion, built
ally observed early in the grieving process are rarely         by George Washington’s adopted son, George Wash-
found before the patient’s actual death, no matter             ington Parke Custis) and 200 acres of ground imme-
how early the warning. In addition, they note that             diately surrounding it were designated officially as
grief implies that there has been a loss; to accept a          a military cemetery on June 15, 1864, by Secretary
loved one’s death while he or she is still alive can           of War Edwin M. Stanton. The primary mission of
leave the bereaved vulnerable to self-accusation for           Arlington National Cemetery is to function as the
having partially abandoned the dying patient.                  nation’s premier military cemetery and shrine hon-
Finally, anticipation of loss frequently intensifies           oring those men and women who served in the
attachment to the person.                                      Armed Forces. More than 260,000 people are cur-
                                                               rently buried at Arlington Cemetery, and an average
Cook, Alicia Skinner, and Daniel S. Dworkin. Helping the       of 23 funeral services are conducted each weekday.
   Bereaved: Therapeutic Interventions for Children, Adoles-   Veterans from all the nation’s wars are buried there,
   cents, and Adults. New York: Basic Books, 1992.             from the American Revolution through the Iraq
Gilbert, Kathleen R. “Anticipated Losses and Anticipatory      War of 2003. Pre-Civil War dead were reinterred
   Grief.” Available online. URL: http://www.indiana.edu/      after 1900.
   ~famlygrf/units/anticipated.html. Updated November             Veterans and public officials meeting any of a
   1, 2001.                                                    dozen criteria are eligible for in-ground burial in
Nussbaum, Jon F., et al. Communication and Aging. Mah-         Arlington National Cemetery. These criteria gener-
   wah, N.J.: Lawrence Erlbaum Associates, 2000.               ally cover active duty members of the Armed
Watstein, Sarah Barbara. “Grief and AIDS,” in The AIDS         Forces, retired or decorated veterans, presidents of
   Dictionary. New York: Facts On File, 1998.                  the United States, veterans who also held elective
32 arrangements

office, and certain relatives of those with military      hydration and nutrition in these patients may make
and governmental eligibility.                            the patient live a little longer but not always.
    In addition to in-ground burial, Arlington              Some controversy swirls among medical and reli-
National Cemetery also has one of the larger colum-      gious ethicists as to whether dying patients should be
baria for cremated remains in the country. Four          force-fed via AHN. Referring to findings by Bernat
courts are currently in use, each with 5,000 niches.     and Mogielnicki, the West Virginia Department of
When construction is complete, there will be nine        Medicine explains:
courts with a total of 50,000 niches; capacity for
100,000 remains. Any honorably discharged vet-              Courts in the United States have found that artifi-
eran is eligible for inurnment in the COLUMBARIUM.          cial nutrition and hydration are medical treatments
    Partly because of its historical significance and        and can be administered or refused as can any other
partly due to the moving Changing of the Guard              treatment. There is no reason why food and water
ceremony at the TOMB OF THE UNKNOWNS, the ceme-             should be considered any more essential to human
tery also has become one of the most visited tourist        life than oxygen, or why the artificial provision of
sites in the Washington area, serving approximately         food and water should be treated differently from
four million visitors annually.                             mechanical ventilation.
    The official Web site—http://www.arlington                  In most cases where refusal of food and water is
cemetery.org—offers many pages of historical infor-         considered it would seem preferable to withdraw
mation, maps, qualifications for burial, and funeral         both nutrition and hydration. When both are with-
procedures. The mailing address is Arlington                drawn death can be expected due to electrolyte
National Cemetery, Arlington, VA 22211.                     imbalance and dehydration in 10–14 days; the con-
    See also NATIONAL CEMETERIES.                           tinuation of fluids may prolong the dying process
                                                            by many weeks.
                                                                Contrary to popular opinion and perhaps to the
arrangements Also called final arrangements;                intuitive feelings of healthy people, patients for
activities associated with the care and disposition         whom nutrition and hydration support is discon-
of a human body following death. Commonly used              tinued do not normally experience thirst or starva-
to cover all the preparations for a funeral, including      tion. Terminal patients who are given normal fluid
the arrangements associated with a ceremony fol-            replacement often show signs of fluid overload,
lowing the death. Funeral directors usually use it to       including pulmonary edema. Dehydration may
mean the disposition of the body.                           decrease vomiting and diarrhea and diminish the
                                                            need to suction secretions. Dry mouth and lips can
                                                            be relieved with lubricants and ice.
artificial hydration and nutrition (AHN)        Com-             In terminal patients where nutrition and hydra-
monly known as tube feeding, AHN is the intro-              tion are not provided artificially, the wishes of the
duction of nutritional formulas and water into a            patient refusing food and water should be honored.
patient’s body by means of tubes, catheters, or nee-        The refusal of food and water is part of the normal
dles inserted into veins (IV feeding); through the          dying process.
nose, down through the throat, and into the stom-
ach (nasogastric or NG tube); surgically through the     When the decision of whether to initiate or con-
abdominal wall into the stomach (gastrostomy tube        tinue AHN has not been made ahead of time via
or g-tube); or through the abdominal wall into the       ADVANCE DIRECTIVES, family members can find the
small intestine (jejunostomy tube).                      making of such a decision agonizing. Janine Marie
    Artificial nutrition and hydration are sometimes      Idziak, Ph.D., a health care consultant for the
given to people while they recover from a tempo-         Catholic archdiocese of Dubuque, Iowa, writes:
rary problem and are unable to eat or drink. AHN
may also be given to people who have an advanced,           Culturally, offering food is a sign of caring and
life-threatening illness and are dying. Artificial          hospitality. We can think of mothers providing
                                                                                         art therapy and grief 33

   food for their infants. Most people enjoy sharing a        There should be a presumption in favor of providing
   meal with family members and friends, especially           nutrition and hydration to all patients, including
   on holidays and special occasions. Food can be a           patients who require medically assisted nutrition
   part of religious rituals. Thus it is not surprising       and hydration, as long as this is of sufficient benefit
   that, when someone we love is unable to take               to outweigh the burdens involved to the patient.
   food and drink naturally, we want to “feed” them
   in some way.                                            Thus, it is considered morally permissible to forgo
                                                           (withhold or withdraw) artificial nutrition and
However, a decrease and loss of appetite is a natu-        hydration when this procedure does not provide
ral part of the body shutting down in the dying            benefits to the patient sufficient to outweigh its bur-
process. With respect to the use of artificial nutrition    dens for the patient.
and hydration for persons who are dying, Lynn and             Noting that “some state Catholic conferences,
Harrold offer this advice:                                 individual bishops, and the NCCB Committee on
                                                           Pro-Life Activities have addressed the moral issues
   The evidence from medical research and experi-          concerning medically assisted hydration and nutri-
   ences of clinicians suggest that dying people are       tion,” this document goes on to say:
   often more comfortable without artificial hydra-
   tion, whether provided by a feeding tube or IV.            These statements agree that hydration and nutrition
   Until this generation, everyone who died a natural         are not morally obligatory either when they bring no
   death died without artificially supplied fluids. The         comfort to a person who is imminently dying or
   stopping of eating and drinking has always been            when they cannot be assimilated by a person’s body.
   part of the last phase of a terminal condition. Only
   recently have people been afraid that not providing     Thus, clinical evidence that patients may well die
   food and fluid through a tube would cause some-          more comfortably without artificially supplied fluids
   one to “starve to death.” There is no medical or        is very important and relevant in making our moral
   clinical evidence that not using a feeding tube or IV   judgments about using or forgoing artificial nutri-
   leads to a more painful death. In fact, the research    tion and hydration in end-of-life care.
   says just the opposite.
                                                           American Dietetic Association. “Position of the American
As Lynn and Harrold point out, there is increasing            Dietetic Association: Issues in Feeding the Terminally
evidence that patients who are allowed to die with-           Ill Adult.” American Dietetic Association Journal no. 8
out artificially supplied fluids die more comfortably           (August 1992): 996–1002, 1005.
than patients who receive such treatment. Natural          Bernat, J. L., B. Gert, and R. P. Mogielnicki. “Patient
dehydration can reduce the patient’s secretions and           Refusal of Hydration and Nutrition.” Archives of Internal
excretions, thus relieving breathing problems and             Medicine 153, no. 24 (December 24, 1993): 2723–2728.
decreasing problems with vomiting and inconti-             Lynn, Joanne, and Joan Harrold. Handbook for Mortals:
nence. Less fluid in the body results in less frequent         Guidance for People Facing Serious Illness. New York:
urination, and in turn, less risk of skin breakdown           Oxford University Press, 1999.
and bed sores. Less fluid in the body means less
pressure on tumors, and hence less pain for the
patient. Indeed, the natural process of dehydration        art therapy and grief Art therapy is the therapeu-
leads to death in ways that produce a sedative effect      tic use of the visual arts, with the assistance of a
on the brain just before death, thus decreasing the        trained professional, to promote emotional healing.
need for pain medication.                                  Professional art therapists use the shapes and pic-
   Regarding artificial nutrition and hydration, the        tures that their clients make as a means of nonverbal
Ethical and Religious Directives for Catholic Health       communication that can lead to a better under-
Care Services from the National Conference of              standing of the client’s behavior. Art therapy is some-
Catholic Bishops (1994) states:                            times used to help people work through the grieving
34 ashes

process. Many people are unable to fully express their           Ferszt et al. note, in fact, that the use of art in
feelings of grief through words, and art therapy offers      bereavement has focused primarily on children.
them an opportunity to express their feelings non-           “The positive effects of art therapy in bereavement
verbally through the use of art materials.                   as reported anecdotally and in case studies are
    Although art therapy as a profession did not             thought to be generally high. Art provides a natural
come into its own until the 1940s, making art to             avenue for children to express sadness, anger, and
“process” a loss is certainly not new. Hill writes, “In      other difficult and often confusing emotions safely.
one sense, humankind may have developed art to               The finished expressions of art also provide a sense
alleviate or contain feelings of anxiety, fear, crisis,      of gratification, allowing the person to see the out-
and threat as well as to mark the importance of              comes of her or his own creative resources.”
events such as death through the creation of visual              Although fewer studies have been reported on
imagery. The desire to self-express through an art           the use of art therapy for adults coping with grief,
form during times of mourning has been explored              several reports do extol its effectiveness, noting that
by many.”                                                    it has been used with survivors of recent tragedies
    In Art as Culture: An Introduction to the Anthropology   like the Oklahoma City bombing and 9/11 disasters.
of Art (Bergin & Garvey, 1999), Evelyn Payne Hatcher             The American Art Therapy Association, founded in
writes:                                                      1969, is a nonprofit organization that provides stan-
                                                             dards of professional competence, plus develops and
   Whatever the theoretical explanation, it is clear         promotes knowledge about the field of art therapy.
   that art somehow helps human beings cope with
                                                             American Art Therapy Association
   the trauma of death. Beauty and art forms have
                                                             1202 Allanson Road
   been part of funeral ceremonies since Neanderthal
                                                             Mundelein, IL 60060–3808
   times. This universal human problem is met every-
                                                             (888) 290–0878 or (847) 949–6064
   where with symbolic solutions to satisfy the mind
                                                             (847) 566–4580 (fax)
   and esthetic solutions to release the emotions.
                                                             info@arttherapy.org
                                                             http://www.arttherapy.org
    Some debate is ongoing as to whether the art is
itself a complete form of therapy or a strategy for          Clements, P. T., Jr., K. M. Benasutti, and G. C. Henry.
conducting therapy. Generally, though, most psy-                 “Drawing from experience.” Journal of Psychosocial
choanalysts see art therapy as a means for “seeing”              Nursing and Mental Health Services 39, no. 12 (December
the patient’s thoughts and feelings. Ferszt et al. add           2001): 12–20.
that “Art making can be therapeutic both during              Ferszt, Ginette G., et al. “Transformation through Griev-
the process of creation and afterward as a means of              ing: Art and the Bereaved.” Holistic Nursing Practice 13,
reflection. The sensory act of touching, seeing, and              no. 1 (October 1998): 68–75.
smelling the art materials in the process of art mak-        Hill, Malinda Ann. “Healing Grief through Art: Art Therapy
ing awakens the senses, taking the person into a                 Bereavement Group Workshops.” Available online.
deeply expressive place that may be difficult to                 URL: http://www.drawntogether.com/healing.htm.
access by cognitive and verbal approaches.”                      Downloaded April 19, 2003.
    Dealing with grief after exposure to a sudden
traumatic death can be an especially painful and
personal experience for children. According to               ashes The commonly used, but inaccurate, term
Clements et al., “Drawings are an expressive                 for the CREMAINS, or cremated remains, which more
method that can provide a conduit for identifying            closely resemble finely crushed sea shells or coarse
and understanding issues requiring therapeutic               sand. Final disposition of ashes will vary according
intervention and follow up.” Some children find              to family wishes, local laws, and religious require-
expressing their grief through drawing, working              ments. In many cases, the cremation ashes are scat-
with clay, painting, and other art mediums more              tered or buried in gardens of remembrance. A few
helpful than expressing their grief through words.           crematoria have niches where urns may be placed,
                                                  Asian Americans/Pacific Islanders (AAPI) and death 35

but these are usually on a rental basis and if not       death and dying are rooted in Asian cultural values
renewed periodically the ashes will be scattered or      such as filial piety, centrality of the family, and
buried. Some families prefer to have the ashes           emphasis on hierarchy. “In addition, strains of Con-
placed in an urn for burial in a family grave, scat-     fucianism, Buddhism, Taoism, and local folklore are
tering in some spot meaningful to the deceased,          embedded in these practices and attitudes.”
such as a mountaintop or at sea, or kept in some             Native Hawaiian or Other Pacific Islanders are
memorial location. If ashes are scattered on the         people having origins in any of the original peoples
ground, weather and biochemical action quickly           of Hawaii, Guam, Samoa, or other Pacific Islands,
break down the ashes to form part of the earth, and      even if they do not live in the Pacific Islands. Accord-
within a short time there is no trace of them.           ing to the 2000 Census, those who identify only as
   See also CREMATION.                                   NHOPI comprise 0.1 percent of the American popu-
                                                         lation, or almost 400,000 individuals.
                                                             Complicating this attempt to differentiate among
Asian Americans/Pacific Islanders (AAPI) and death        these population groups, only one race is currently
For statistical purposes, the U.S. government and var-   reported in DEATH CERTIFICATE data. Thus, any mor-
ious health agencies have for years grouped the          tality statistics for Asian Americans/Pacific Islanders
diverse and heterogeneous group of people whose          from the 1990s through 2010 are likely to show
roots span the globe from the Far East to Southeast      overlap, “bridging,” and differing categories for
Asia to Polynesia to Hawaii into one population seg-     these population groups.
ment they call Asian Americans/Pacific Islanders or
Asian Pacific/Islander Americans (APIA) or Asian/                        Leading Causes of Death
Pacific Islanders (AIA). Some researchers have had a      The Centers for Disease Control reports that Asian
problem with such aggregated study populations           Americans represent both extremes of socioeco-
when it comes to medical and mortality research,         nomic and health indices: Although more than a
noting that the research on ethnic health disparities    million Asian Americans live at or below the federal
is especially fragmented in Asian/Pacific Islanders.      poverty level, Asian-American women have the
Part of the problem rests with unclear definitions of     highest life expectancy of any racial and ethnic pop-
ethnicity, with much of the information self-reported    ulation. Asian Americans suffer disproportionately
by individuals and complicated by mixed ethnicity.       from certain types of cancer, tuberculosis, and
   For the first time, the 2000 census allowed peo-       Hepatitis B. Factors contributing to poor health out-
ple to report more than one race for themselves and      comes for Asian Americans include language and
their household members and also separated the           cultural barriers, stigma associated with certain con-
category for Asian or Pacific Islander persons into       ditions, and lack of health insurance.
two groups: Asian Americans, and Native Hawaiian             The 10 leading causes of death in the United States
or Other Pacific Islanders (NHOPIs).                      in 2000 for Asian Americans were: (1) cancer, (2)
   Asian Americans are people having origins in          heart disease, (3) stroke, (4) unintentional injuries,
any of the original peoples of the Far East, South-      (5) chronic lower respiratory disease, (6) influenza
east Asia, or the Indian subcontinent. According to      and pneumonia, (7) diabetes, (8) suicide, (9) nephri-
the 2000 U.S. Census, those who identify only as         tis, nephrotic syndrome, and nephrosis, and (10)
Asian-American comprise 3.6 percent of the Amer-         birth defects.
ican population, approximately 10 million individ-           According to the Centers for Disease Control,
uals. The Census Bureau projects that the Asian-         NHOPIs generally experience poorer health than
American population will grow to 37.6 million indi-      the American population as a whole: they are more
viduals by the year 2050, comprising 9.3 percent of      at risk for developing and dying from cancer, heart
the population.                                          disease, diabetes, and other diseases. Factors con-
   Chinese Americans are the most rapidly growing        tributing to poor health outcomes among NHOPIs
Asian American group, and Yick and Gupta found           include cultural barriers, limited access to health
that many of their attitudes and practices about         care, and poor nutrition and lifestyle.
36 assisted suicide

   The 10 leading causes of death in the United            another individual. In 1997 the U.S. Supreme Court
States in 2000 for Native Hawaiians and Other Pacific       ruled that assisted suicide is not a constitutional
Islanders were: (1) cancer, (2) heart disease, (3)         right. This means that states are constitutionally
stroke, (4) unintentional injuries, (5) chronic lower      allowed to prohibit assisted suicide. The Court also
respiratory disease, (6) influenza and pneumonia,           recognized the distinction between suicide, involv-
(7) diabetes, (8) suicide, (9) nephritis, nephrotic syn-   ing the direct and intentional taking of life, and
drome, and nephrosis, and (10) birth defects.              decisions to refuse treatment or use of pain med-
   The Centers for Disease Control reports show            ication, which may indirectly result in hastened
that through December 1998, 2,504 Asian/Pacific             death but not involve an intent to take life.
Islander males and 286 Asian/Pacific Islander                 Currently, assisting suicide is a crime in all but
females had died of AIDS-related causes.                   one state, and is directly banned by statute in 38
   Motor vehicle crashes are the number one cause          states. In 1994 Oregon voters approved a law that
of death for Asian/Pacific Islanders ages one to 24.        legalizes physician-assisted suicide for persons with
   According to the National Women’s Health Infor-         terminal conditions. While it is against the law in
mation Center, the four leading causes of death            most states to directly assist another person in tak-
among Asian American/Pacific Islander women are,            ing his or her own life, it is not illegal to give gen-
in order of prevalence, cancer, heart disease, stroke,     eral information to people, especially when the
and unintentional injuries. These women have               information given is obtained from sources already
lower death rates from most major diseases—                in the public domain, such as in bookstores or
including heart disease, stroke, and HIV/AIDS—             libraries.
than Caucasian women. Their mortality rates from              The question remains whether federal law
breast cancer and all cancers combined was the low-        allows the states to permit assisted suicide and
est of all population groups in 1996. However, sui-        under what circumstances. By classifying persons
cide ranked eighth among the deaths in Asian               with terminal conditions as eligible for suicide assis-
American/Pacific Islanders.                                 tance, while continuing to treat suicide assistance
   See also HAWAIIAN NATIVE BURIAL CUSTOMS.                involving non-terminally ill suicide victims as a
                                                           crime, the Oregon law raises serious equal protec-
Yick, A. G., and R. Gupta. “Chinese Cultural Dimensions    tion questions. The U.S. Department of Justice has
   of Death, Dying, and Bereavement: Focus Group Find-     announced that it will not enforce federal laws gov-
   ings.” Journal of Cultural Diversity 9, no. 2 (Summer   erning the dispensing of dangerous drugs against
   2002): 32–42.                                           Oregon doctors who participate in legalized assisted
                                                           suicide. Congress is considering legislation, backed
                                                           by the American Medical Association and the
assisted suicide Hastening one’s own death with            National Hospice Organization, to override the Jus-
assistance from another with the intent of ending          tice Department.
suffering from a chronic or terminal disease. The             See also EUTHANASIA; MERCY KILLING; PHYSICIAN-
importance of having assistance, in the minds of           ASSISTED SUICIDE.
those who seek it, is that the possibility of assis-
tance enables them to stay alive longer than if they       Evans, Glen, Norman L. Farberow, and Kennedy Associ-
had to complete suicide alone, since at some point            ates. “assisted suicide,” in The Encyclopedia of Suicide,
the illness might progress to the point at which they         Second Edition. New York: Facts On File, 2003.
could no longer hasten their death without assis-
tance. The option of assisted suicide is important to
some, even if they never use it, as a means to ensure      Association for Death Education and Counseling
some control over their suffering. Assisted suicide is     (ADEC) One of the oldest interdisciplinary organ-
referred to in many statutes as “abetted” suicide. It      izations in the field of dying, death, and bereave-
has been defined as giving advice on methods of             ment, ADEC began in 1976 as the Forum for Death
suicide, or otherwise facilitating the suicide of          Education and Counseling. Its membership is made
                                                                                                     autopsy 37

up of mental and medical health personnel, educa-        autoerotic deaths Accidental deaths that occur
tors, clergy, funeral directors, and volunteers. ADEC    during individual, usually solitary, sexual activity
offers numerous educational opportunities through        in which a device, apparatus, prop, chemical, or
its annual conference, courses and workshops, and        behavior that was employed to enhance the sexual
a certification program. It publishes a newsletter,       stimulation of the deceased in some way causes
The Forum. Working to promote and share research,        unintended death. Autoerotic asphyxia induces a
theories, and practice in dying, death, and bereave-     state of oxygen deficiency, which enhances sexual
ment, ADEC’s primary goal is to enhance the abil-        excitement and orgasm. It has been practiced for
ity of professionals and lay people to better meet the   centuries, and there are many reports of fatalities.
needs of those with whom they work in death edu-         Most reported cases are of young males, although it
cation and grief counseling. Contact information:        is not unheard of among women.
                                                             Cases of autoerotic asphyxia are often labeled as
Association for Death Education and Counseling
                                                         suicide, or are under-reported because of embar-
    (ADEC)
                                                         rassment of relatives or misidentification of the ini-
342 North Main Street
                                                         tial clinical manifestations. It may be that autoerotic
West Hartford, CT 06117–2507
                                                         asphyxial death is far more common than realized.
(860) 586–7503
                                                         According to Kirksey et al., “Many emergency
(860) 586–7550 (fax)
                                                         nurses and physicians lack adequate knowledge
info@adec.org
                                                         about this phenomenon to make an accurate diag-
http://www.adec.org
                                                         nosis. Family members are often reluctant or
                                                         unwilling to provide enough data surrounding the
                                                         circumstances in which the patient was found, and
Association for Gravestone Studies, The (AGS)
                                                         the cause of death is mislabeled as suicide. Auto-
Founded in 1977 for the purpose of furthering the
                                                         erotic asphyxia is frequently labeled as a sexual
study and preservation of gravestones. AGS is an
                                                         aberrancy and an act that society would rather not
international organization with an interest in grave-
                                                         acknowledge.”
markers of all periods and styles. Through its publi-
cations, conferences, workshops, and exhibits, AGS
                                                         Kirksey, K. M., et al. “Autoerotic Asphyxia in Adoles-
promotes the study of gravestones from historical
                                                            cents.” Journal of Emergency Nursing 21, no. 1 (February
and artistic perspectives, expands public awareness
                                                            1995): 81–83.
of the significance of historic gravemarkers, and
encourages individuals and groups to record and
preserve gravestones. Members receive the AGS
Quarterly and Markers, an annual scholarly journal.
                                                         autopsy An examination of a dead body following
                                                         dissection in order to allow observation by the
Contact information:
                                                         pathologist. An autopsy involves observing both the
The Association for Gravestone Studies                   external and internal structures of the body in order
278 Main Street                                          to gather information about that person and the
Suite 207                                                person’s death, such as evidence of any abnormal
Greenfield, MA 01301                                      development, natural disease, injury, or unnatural
(413) 772–0836                                           event. If autopsy is not required by law, such as
info@gravestonestudies.org                               when a crime is suspected, the legal next-of-kin
http://www.gravestonestudies.org                         must sign an autopsy permit. The most common
                                                         reason for performing an autopsy is to establish the
                                                         true cause of death and/or the manner of death,
asystole Also called “flat line.” Cardiac standstill      such as homicide, accident, or suicide. But autopsy
with no electrical activity or contractions of the       can also be used to compare what the physicians
heart (heartbeat). It eventually occurs in all dying     knew with what is found, assess the quality of med-
patients.                                                ical care, teach doctors and medical students, check
38 autopsy

the effectiveness of new treatments, find the cause        erosity of donation. Buddhism, which developed a
of new or altered diseases, and reassure family           denial of appearances, is finding ways to dialogue
members.                                                  with the need of medical practices in the western
   In the United States, dissection of the human          world.”
body has been practiced since the mid-1700s,                  Autopsy records in hospitals, medical examiner,
although it was not unusual during the early days         and coroner offices are usually kept for decades or
for riots and acts of violence to occur against physi-    longer. Family members can request and expect to
cians, anatomy instructors, and medical students in       obtain a copy of the autopsy report many years
protest of the practice.                                  later. Some states require that the next-of-kin fam-
   In a history of autopsy and religion Seilhean          ily member make the request.
notes that “No main religion practiced in the regions         See also BODY SNATCHING.
where autopsies are performed forbids it definitely.
Judaism and Islam accept it as far as its usefulness is   Seilhean, D. “Autopsy and Religions.” Bulletin de l’Acade-
demonstrated. Christianity encourages the gen-               mie Nationale de Medecine 185, no. 5 (2001): 888–889.
                                                                                                            B
bad death     A medical term that palliative care pro-          to talk about whatever he or she feels was left
ponents use to describe a person who dies in pain,              undone or needs to be made right, and to express
under psychological distress, and unable to com-                their feelings. The bargaining usually is private and
municate his or her needs. Medical ethicists describe           on a spiritual level.
a bad death as a death characterized by needless                   See also ACCEPTANCE; ANGER; DENIAL; DEPRESSION.
suffering, dishonoring of patient and family wishes
or values, and a sense among participants or
observers that norms of decency have been                       beneficiary An individual or organization that
offended. It has also been described as a death char-           receives funds from any source. The term benefici-
acterized by poor symptom control, physician aban-              ary is commonly used to mean the individual, insti-
donment, or inadequate closure.                                 tution, trustee, or estate named in an insurance
    Bad death is also a Christian religious term used to        policy as the recipient of the funds in the policy, in
describe a person who dies in a state of mortal sin—            the event the policyholder dies. Beneficiaries may
without receiving the Sacrament of the Sick. The                also be named in wills, retirement plans, annuities,
threat of suffering a bad death by not adhering to a            and other contracts. In addition to naming a specific
list of religious requirements on one’s deathbed                beneficiary to receive the proceeds of a life insurance
dates back to before the Reformation.                           policy (permanent or term), the Insurance Informa-
                                                                tion Institute suggests naming a secondary or “con-
                                                                tingent” beneficiary, in case the insured outlives the
bargaining      As described by psychologist ELISA-             first beneficiary. If there is no living beneficiary, the
BETH  KÜBLER-ROSS, the third stage of dying, when               proceeds will be paid to the insured’s estate and have
the terminally ill patient attempts to buy time by              to go through probate proceedings, resulting in a
negotiating, usually with God but sometimes with                possible delay before the family receives the money.
physicians or with anyone or anything that the per-             If the proceeds go into the estate, these proceeds
son believes can protect him or her from death—                 may be subject to estate taxes. The Insurance Infor-
“Let me live until . . . or . . . months longer, and I          mation Institute has additional information.
will . . .” In return for a cure or at least a delay of
death, the patient will go to church, give to chari-            The Insurance Information Institute
ties, meet some family obligation, or fulfill any               110 William Street
number of promises. It may involve praying, seek-               New York, NY 10038
ing alternative treatments, or promising better                 (212) 346–5500
behavior in exchange for postponement of the                    www.iii.org
inevitable. During this stage, the patient may be
exhausted and show signs of depression. He or she
may experience weakness and shortness of breath if              benefits and burdens      In the context of health
his or her situation is discussed, an acute situation           care, a guideline commonly used to determine
that may last from several minutes to an hour. It is            whether or not to withhold or withdraw medical
best during this phase to allow the grieving person             treatments. Benefits are the outcomes that a specific

                                                           39
40 bequest

medical procedure or treatment in all probability          against one’s will.” The terms GRIEF, bereavement,
will be successful in attaining. Outcomes may be           and MOURNING are often used in place of each other,
medical (the heart beats again) or functional (the         but they have different meanings. Bereavement is
patient being able to once again walk), or may sup-        the period after a loss during which grief is experi-
port the patient’s values (the patient is able to die at   enced and mourning occurs. After someone close to
home as he wished). Burdens are the physical and           you dies, you go through a process of mourning.
emotional pain, discomfort, suffering, and/or losses       Grief is the visible sign of that mourning—a coping
that a medical procedure or treatment will impose.         mechanism—and encompasses a wide range of
For example, resuscitation may cause the patient to        physical and emotional symptoms that you experi-
breathe again—a benefit, but it may also cause the          ence after a loss. Bereavement is not restricted to
dying patient extended suffering and further finan-         people who have lost someone they have known
cial burden.                                               for a long time. It is also experienced by people who
   The benefits and burdens of care may be differ-          have had stillbirths, miscarriages, or lost a young
ent for the medical team, for the patient, and for the     baby. The duration and expression of “normal”
family. And they will vary among patients according        bereavement vary considerably among different
to the personal value systems of the persons               cultural groups, and also depend on how attached
involved. Thus, according to PARTNERSHIP FOR CAR-          the person was to the person who died, and how
ING, “Discussions of the benefits and burdens of           much time was spent anticipating the loss.
medical treatments should occur within the frame-
work of the patient’s overall goal for care.”
                                                           bereavement leave       Time allowed off the job due
                                                           to the death of a family member. The typical
bequest       A gift given after death. Most usually, a    bereavement leave is three to five days for a close
bequest is tangible property, such as cash, real estate,   relative, such as a parent, child, or spouse, although
or securities, given or left to an individual or organ-    some firms will extend that on an as-needed basis.
ization in a will. According to MedLawPlus.com,            Bereavement leave is not required by federal or state
which offers legal forms such as wills, a bequest          law, but is a holdover from old labor agreements. An
may be “specific” or “residual.” A specific bequest is       increasing number of employers are recognizing
one whereby the maker of a Last Will gives a BENE-         domestic partner relationships as family and thus
FICIARY a specific sum of money, a specific item of          qualified for bereavement leave. One human
property, or a well-defined class or kind of property       resources survey found that bereavement leave
(i.e., “all stocks that I own” or “my coin collection”).   today averages 3.4 days a year, up from 3.1 days in
A residual (or residuary) bequest is the disposition       1970, but experts say that’s still insufficient for most
by the maker of a will of all that remains after pay-      people. Not only do the funeral logistics take awhile
ment of debts of the estate, administrative expenses       for today’s far-flung families, but also the grieving
of the estate, charitable bequests, disposition of per-    process, when worker effectiveness falls to low lev-
sonal effects, and specific bequests. In effect, it is      els, invariably takes longer than three days.
what is left over after the completion of all other           See also EMPLOYEES’ NEEDS AS END-OF-LIFE CARE-
outflows from the estate directed by the will. The          GIVERS.
residual bequest may go to one beneficiary, multi-
ple beneficiaries in equal shares, or multiple bene-
ficiaries in designated percentages (with the total         bier    A raised stand on which a corpse or COFFIN
percentages assigned adding up to 100 percent).            containing a corpse is placed before burial. A coffin
“Bequest” is also used for BODY DONATION.                  along with its stand is also sometimes referred to as
                                                           a bier. Among the ancient Hebrews a bier was sim-
                                                           ply an open coffin or a flat wooden frame, on which
bereavement To be deprived by death. Bereave-              the body of the dead was carried from the house to
ment literally means to “tear up, the loss, the issue      the grave.
                                                                                                      Black Death 41

bioethics Study of the challenging moral and eth-                 from which resuscitation of the body as a whole is
ical issues that face medical researchers and health              impossible by currently known means. It is the
caregivers resulting from the rapid advances in the               point at which the failure of the brain, respiratory,
sciences, especially medicine and biology, that affect            and circulatory systems are irreversible. The poten-
our lives today from birth through death. Histori-                tial of biomedicine to prolong the process of biolog-
cally, ethics was in the realm of theologians, but                ical death, possibly indefinitely for some patients,
along with the invention of life-supporting tech-                 has helped spur the BIOETHICS debate.
nologies such as artificial respirators and heart-lung
machines in the 1960s, ethical questions arose as to
their use, resulting in medical ethics as a distinct              Black Death Form of bubonic plague that spread
field in the 1970s, particularly in the United States.             over Europe during the 14th century, killing as
Professional philosophers developed university                    much as one-half of the European population,
courses on bioethics. In the 1980s, two California                according to some estimates, although some histori-
doctors were charged with first-degree murder after                ans say it was more likely one-third. It began in the
they shut off a patient’s breathing machine with the              early 1330s in China, which was one of the world’s
family’s consent. The doctors were not prosecuted,                busiest trading nations, causing it to spread rapidly to
but the incident led to hospitals and aged-care facil-            western Asia and Europe. Bubonic plague is charac-
ities nationwide employing bioethics experts to                   terized by fever, chills, vomiting, diarrhea, and a
advise them on the ethical issues and challenges                  painful swelling of the lymph glands called buboes,
they now face. In November 2001 the President’s                   the basis of its name. The disease also causes red
Council on Bioethics was formed.                                  spots on the skin that turn black. The plague made
    Ethical challenges having to do with death and                its way west across Asia to the Black Sea by 1347,
dying include managed care, end-of-life treatment,                spreading in 1348 to England, where people called it
EUTHANASIA, and ASSISTED SUICIDE. In bioethics                    the “Black Death” because of those black spots.
issues, there are no cut-and-dried, one-size-fits-all                  Each winter the disease would seem to disap-
answers—only alternatives and considerations.                     pear, but only because fleas—which were carrying
Physicians, theologians, professors, philosophers,                it from person to person—were dormant then. Each
scientific researchers, pharmacists, and lawyers all               spring, the plague attacked again, killing new vic-
sit on bioethics committees. Even religions hold no               tims. After five years, at least 25 million people were
consensus about end-of-life choices. Most religions               dead—actual death numbers, especially those of
hold all life as sacred, but that belief is not absolute          peasants, were not kept in Medieval Europe. Small
in all instances, according to theologians.                       outbreaks continued until it finally disappeared in
                                                                  the 1600s. Because of the tremendous loss of life,
Fletcher, John C., Franklin G. Miller, and James M. Hum-          including much of the labor force, plus a doubting
   ber, eds. The Nature and Prospects of Bioethics: Interdisci-   of religious beliefs (Why would God or the saints
   plinary Perspectives. Totowa, N.J.: Humana Press, 2003.        allow this to happen?), the Black Death had a pro-
Walter, Jennifer K., and Eran P. Klein, eds. The Story of         found effect on the men and women of medieval
   Bioethics: From Seminal Works to Contemporary Explo-           Europe. According to Lynn Harry Nelson, Emeritus
   rations. Washington, D.C.: Georgetown University               Professor of Medieval History at the University of
   Press, 2003.                                                   Kansas, it led to “new attitudes toward death, the
                                                                  value of life, and of one’s self. It kindled a growth of
                                                                  class conflict, a loss of respect for the Church, and
biological death Somatic or physical death; the                   the emergence of a new pietism (personal spiritual-
irreversible breakdown of respiration and conse-                  ity) that profoundly altered European attitudes
quent loss of oxygen utilization by a living organ-               toward religion. Still another effect, however, was
ism. It begins four to six minutes after CLINICAL                 to kindle a new cultural vigor in Europe, one in
DEATH and is the point when brain cells begin dying.              which the national languages, rather than Latin,
Biological death has also been described as the state             were the vehicle of expression. An example of this
42 bodily deterioration as death approaches

movement was Giovanni Boccaccio’s The Decameron,           Disorientation Referred to as “terminal restless-
a collection of tales written in 1350 and set in a         ness,” confusion is common at the end of chronic
country house where a group of noble young men             illnesses, possibly resulting from electrolyte
and women of Florence have fled to escape the              abnormalities. The patient will seem to be unable
plague raging in the city.”                                to find a comfortable or satisfactory position.
                                                           Irregular breathing Long pauses between
                                                           breaths; loud, raspy breathing; labored breath-
bodily deterioration as death approaches         How       ing; many breathing patterns may occur during
each person dies is as unique as the individual who        the person’s final days and hours. Excessive
is dying, but knowing that certain events are typical      secretions in the back of the throat or lungs will
can help a family prepare for the inevitable. Detailed     lead to noisy breathing that sounds like a rattle.
studies of the experience of dying are fairly limited,
                                                           Visual and auditory hallucinations Perhaps
but the available data indicate both a considerable
                                                           from dreaming; some say due to a foreshadowing
degree of commonality in the dying process and
                                                           of the next life, but it is not uncommon for the
enough variability that no uniform model of care-
                                                           dying person to claim he or she has seen or even
giving or preparing for death will suffice.
                                                           talked to someone who died long ago.
    Common physiological signs of imminent death
include:                                                   Convulsions As cells deteriorate and the electri-
                                                           cal impulses between cells begin to falter and mis-
  Increased sleeping Often occurs during final             fire, convulsions can occur. Life may even end in
  days and hours, as if the body systems are shift-        a sudden seizure-like convulsion.
  ing into slow gear prior to their shutting down.         Decreased clarity of sight The dying person’s
  Decreased appetite Normal during the dying               vision will dim or become blurry.
  process, but often difficult for the family to accept     Mottled skin The skin tone will change and
  and understand because the impulse is to force           become darker in blotchy spots.
  food on the loved one so he or she won’t starve.         Odor Necrotic (dying) tissue may cause a bad
  But the dying person likely will not be hungry,          odor, which is, in fact, decaying flesh. Certain
  may not be able to swallow, and will not have the        diseases, such as cancer and diabetes, may lead to
  energy to eat. Providing food or liquids late in         insufficient blood flow, causing the affected parts
  the dying process may actually harm the patient          of the body to slowly die and produce a foul odor.
  by causing fluid imbalances.
  Decreased thirst Thirst usually abates after           In one study of elderly persons on their last day of
  appetite disappears. Even though the dying per-        life, three out of four were confined to bed, and 40
  son will have no interest in drinking, the mouth       percent had difficulty recognizing family. Fifty-five
  and tongue may become dry. Forcing liquids             percent were unable to eat, 44 percent were short of
  down the throat may cause choking, so care             breath, and 33 percent reported some pain.
  givers suggest wetting the lips with ice or lemon          From her nursing experience, Gray observed that
  glycerin swabs, swabbing the mouth with a moist        for many patients there is a sequence of physiolog-
  sponge, putting a drop or two of lemon juice on        ical events during the dying process.
  the tongue to encourage saliva production, or
  using artificial saliva, which is available in drug     • The patient’s sensation and power of motion as
  stores. For some patients, hard candy may help.          well as his reflexes are lost in his legs first and
  Incontinence Loss of bladder and bowel control           gradually in his arms. Pressure on the extremities,
  frequently occurs as the person weakens. It can          such as snug sheets, seems to bother patients.
  be embarrassing for the patient, but happens less      • As peripheral circulation fails, there is a drench-
  frequently as the person eats and drinks less, and       ing sweat, particularly on the upper parts of the
  as the kidneys shut down.                                body, and the body surface cools, regardless of
                                                                                                 body donation 43

  room temperature. Even though the body may                   used to develop improved surgical instruments and
  feel cool to the touch, the patient will not be              techniques. Advance testing reduces the risk to liv-
  aware of being cold, because his internal temper-            ing patients and speeds development of minimally
  ature is quite high.                                         invasive surgical procedures, helping reduce the
• The dying patient always turns his head toward               length of hospital stay, pain, and recovery times.
  the light. As sight and hearing fail, the dying see             Medical education in the United States requires
  only what is near and hear only what is distinctly           more than 8,000 bodies yearly for training tomor-
  spoken to them.                                              row’s physicians, nurses, dentists, and other health
                                                               professionals. Most donated bodies end up in
• The dying patient’s touch sensation is diminished,
                                                               anatomy classes, although some are used to teach
  yet the dying can sense pressure. Some patients
                                                               surgery and other specialty fields.
  do not like to be touched, preferring to blink their
                                                                  The number of body donors has increased signif-
  eyes to communicate.
                                                               icantly in the past few years, with the result that
   See also DYING PROCESS, THE.                                some medical schools may have an over-supply at
                                                               any given time. Therefore, schools now reserve the
Collins, Lois M., and Elaine Jarvik. “At Death’s Door.” The    right to decline a body donation if their facilities are
   Deseret News, September 26, 2002.                           temporarily full. Most will accept bodies only if prior
Field, Marilyn J., and Christine K. Cassel, eds. Approaching   arrangements were made; some only if the deceased
   Death: Improving Care at the End of Life. Washington,       had resided within the same state as the university.
   D.C.: National Academy Press, 1997.                            Other reasons why a medical school may not be
Gray, V. Ruth. “Some Physiological Needs,” in Dealing with     able to accept a body for donation include:
   Death and Dying. Springhouse, N.J.: Intermed Commu-
   nications, 1983.                                            • condition of the body not suitable for their stud-
Kessler, David. The Needs of the Dying. New York: Harper-        ies; for example, certain infectious or vascular
   Collins, 2000.                                                diseases, open wounds (such as unhealed sur-
                                                                 gery or trauma), autopsy, and extreme malnutri-
                                                                 tion or obesity.
body donation Also called whole body donation;                 • missing limb(s) or major organs.
the bequeathing of the body to be used for scientific
purposes following death. Whole body donation has              Because of institutions’ individual needs and
long been a vital practice for the purpose of medical          requirements, it is important that anyone consider-
research and education, but it has not had the wide-           ing whole body donation following death first check
spread media attention as has the more recent                  with those medical schools of interest to see what
ORGAN AND TISSUE DONATION. Most body donors fall               their requirements are. Many schools post their
into three categories: those who want their bodies             body donation conditions on their university Web
to be of use to help others; those who had positive            sites. According to the National Funeral Directors
experiences with their physicians and so want to               Association, medical schools in urban areas tend to
help students become physicians; and those who                 be the ones more often oversupplied; therefore,
want to spare their families the financial costs of             they suggest that when arranging for a body dona-
traditional burial. A person cannot choose to donate           tion, one should also specify whether or not the
both organ and tissue for transplantation and whole            institution may send the body to another school
body for research.                                             that is undersupplied.
   Thousands of bodies are needed each year for                    Institutions are forbidden by law to pay for bod-
such medical research and training. Body donation              ies, but they sometimes will cover some of the costs
contributes to the development of drugs and thera-             involved. For example, upon acceptance of a body
pies to treat such diseases as Alzheimer’s, Parkin-            donation, Dartmouth Medical School will be finan-
son’s, multiple sclerosis, cancer, diabetes, and               cially responsible for removal of the body from a
neurological disorders. Human tissue can also be               hospital, transportation of the body to Dartmouth
44 body following death

Medical School, permits for transportation and cre-          body snatching      The theft of corpses from graves
mation, and cremation.                                       and morgues. The term often refers to a grave-robbing
   Because of the potential savings in funeral costs,        scandal in Great Britain in 1827, before cadavers
industry people say that the recent increase in body         were legally available for dissection and study by
donation is more due to financial concerns than              medical students and when dealing in stolen bodies
benevolent feelings. The family may still be able to         was highly profitable.
receive the cremated remains for later memorial                 William Hare and his accomplice, William Burke,
services, so more and more people are considering            robbed graves in order to sell the corpses and body
body donation as a way of retaining more of their            parts to medical schools for use in autopsies. Not
money for their children and grandchildren’s use.            content with being limited to dead bodies, they
People who donate their whole bodies usually are             began suffocating people in order to have more bod-
older and more concerned about the escalating costs          ies to sell. They were caught, tried, and convicted in
of funerals.                                                 1828. This and other similar cases led to the passage
   According to Guthrie, the typical person who              in Great Britain in 1932 of the Anatomy Act, which
leaves his body to science is white, married, and            permitted the legal acquisition by medical schools of
middle-class. About 95 percent are white and about           unclaimed bodies.
50 percent professional, with just a few more
women than men. African-American participation is
low because of the history of robbing slaves’ graves         Bowlby, John (1907–1990) An English psychia-
and the cultural importance of funeral ceremonies.           trist most noted as a leading researcher and teacher
Although all major religious groups have endorsed            in the field of personality development. His “four
body donation, some sects do object to the practice.         stages of grief” model is of particular historical inter-
   Universities participating in body donation for           est, contrasting with the better-known “five stages”
research and study are governed by strict ethical            model popularized by ELISABETH KÜBLER-ROSS. He
guidelines. These differ from state to state, but usu-       believed that grief results from our biological need
ally include no profiting from body procurement,              for security in the face of danger. Bowlby’s four
protection of identities of donors, and control of           stages are:
students’ behavior around and use of the CADAVERs.
Most medical schools will return the cremated                • Phase of numbing that usually lasts from a few
remains of the donor at no charge to the family.               hours to a week and may be interrupted by out-
Those not returned or claimed are usually buried in            bursts of extremely intense distress and/or anger.
memorial gardens. Many schools hold annual serv-
                                                             • Phase of yearning and searching for the lost fig-
ices to honor those who have given the ultimate
                                                               ure lasting some months or sometimes for years.
donation to their fellow man.
   The National Anatomical Board maintains a                 • Phase of disorganization and despair.
state-by-state listing of body donation programs in          • Phase of greater or lesser degree of organization.
the United States, with full contact information, at
http://www.med.ufl.edu/anatbd/usprograms.html.
   See also BROKERING BODY PARTS.                            brain death Irreversible cessation of all functions
                                                             of the brain. The term is now used to replace the
Guthrie, Patricia. “Living with Death: The Ultimate Gift.”   traditional definition of death by cessation of heart-
   The Atlanta Journal and Constitution, November 29,        beat and respiration. Brain death is considered the
   1998.                                                     legal definition of death, and all but six states have
Lee, Regina. Anatomical Gift: Whole Body Donation Guide.     enacted such a statute. The remaining states recog-
   Atlanta: Consumer Education Services, 1997.               nize brain death by judicial determination. Both
                                                             the American Medical Association and the Ameri-
                                                             can Bar Association approved this definition in
body following death        See DECOMPOSITION.               1988.
                                                                                      breathing patterns 45

    In the most conservative definition of this term, it      According to Steve Emery, procurement coordi-
refers to whole brain death, cessation not only of        nator for the Iowa Statewide Organ Procurement
higher cortical function, but of brain stem function      Organization, there are several ways in which a per-
(lower brain) as well. The Florida statute reads, “For    son may become brain dead:
legal and medical purposes, where respiratory and
circulatory functions are maintained by artificial        • Anoxia caused by drowning, respiratory diseases,
means of support so as to preclude a determination          or drug overdose.
that these functions have ceased, the occurrence of       • Ischemia—blockage of an artery leading to the
death may be determined where there is the irre-            brain or in the brain, heart attack (stoppage of the
versible cessation of the functioning of the entire         heart for a period of time), bleeding in the brain.
brain, including the brain stem, determined in accor-     • Intracranial hematoma caused by a head injury (a
dance with this section. Determination of death pur-        blow to the head) or a ruptured aneurism.
suant to this section shall be made in accordance
with currently accepted reasonable medical stan-          • A gunshot wound to the head—causes destruc-
dards by two physicians licensed under chapter 458          tion of brain tissue and swelling of the brain.
or chapter 459. One physician shall be the treating       • Intracranial aneurysm—the ballooning of a blood
physician, and the other physician shall be a board-        vessel supplying the brain, which can cut off
eligible or board-certified neurologist, neurosurgeon,       blood supply or rupture.
internist, pediatrician, surgeon, or anesthesiologist.”   • Brain tumors that can destroy brain tissue and
In most states, two physicians must declare a person        increase pressure within the brain.
brain dead before organ donation can proceed.
    A person’s heart can still be beating because of      When any of the above occur, they cause swelling
the ventilator and medications helping to keep the        of the brain. Because the brain is enclosed in the
blood pressure normal. Modern resuscitation tech-         skull, it does not have room to swell, thus pressure
niques can maintain the function of the heart,            within the skull increases (this is “intracranial
lungs, and other organs for days, weeks, and even         pressure”). This can stop blood flow to the brain,
months after the life-maintaining centers of the          killing brain cells and causing herniation of the
brain stem tissue have stopped functioning, which         brain (pushing the brain outside of its normal
results in the medical dilemma of a dead brain in an      space). When brain cells die, they do not grow
otherwise living body. On the other hand, the             back, thus any damage caused is permanent and
development of transplant surgery and the need of         irreversible.
viable organs have focused ethical and legal atten-
tion on the desirability of agreeing on the medical
criteria of brain death because the same person can       breathing patterns During the dying process,
be considered legally dead if about to become an          breathing patterns often change. Breathing may
organ donor, and legally alive if not.                    become more irregular, with periods of rapid, shal-
    In 1981 the President’s Commission for the            low breath alternating with periods of no breathing.
Study of Ethical Problems in Medicine and Bio-            The dying person may also experience periods of
medical and Behavioral Research developed stan-           rapid, shallow, pant-like breathing. These patterns
dards for the determination of brain death which,         are very common and are caused by excess carbon
with some modifications, are accepted worldwide.           dioxide in the body as well as decreased circulation
    Brain death can be determined in several ways:        in the internal organs.
no electrical activity in the brain (determined by an        The Hospice Care Network stresses that changes
EEG), no blood flow to the brain (determined by            in breathing patterns are most likely more distress-
blood flow studies), and absence of function of all        ing to family and friends than to the dying person.
parts of the brain—no movement, no response to            “This is a natural pattern of breathing for someone in
stimulation, no breathing, no brain reflexes (deter-       the process of dying. Elevating your loved one’s head
mined by clinical assessment).                            and/or turning him/her on his/her side may help.”
46 brokering body parts

   According to death and bereavement counselor            University’s body donation program, expressed con-
R. David San Filippo, the process of dying is similar      cern that “the same regulatory bodies aren’t over-
to the process of birthing. “The dying person, very        seeing the activities of private businesses in the same
often, demonstrates similar breathing patterns as          way they do for public agencies and tissue banks
the expectant mother who is undergoing labor con-          associated with medical schools and hospitals.”
tractions. As death approaches, the dying person’s            See also BODY DONATION.
breathing becomes more labored and the fear of the
unknown becomes more prominent. The expectant
mother and her coach are taught breathing rhythms          Buddhism and death        Founded in India around 525
and mental exercises to ease the birthing process.         B.C.E.  by Siddhartha Gautama, called the Buddha,
Similar breathing and mental exercises can be              Buddhism is both a religion and a philosophy, with
taught to the dying person and his or her coach to         an estimated 570 different varieties. Today there are
ease the dying process.”                                   more than 300 million Buddhists throughout the
                                                           world, with most living in China and Japan, and with
                                                           sizable populations in Thailand, Vietnam, and Myan-
brokering body parts The legal buying of body              mar. The American Religious Identification Survey
parts or corpses from “donors” in order to resell          (ARIS 2001) by the Graduate Center of the City Uni-
body parts to private and public research programs.        versity of New York found that the estimated num-
Federal laws prohibit buying or selling organs for         ber of American adults who identify themselves as
transplant, but organs, tissue, and bones may be           Buddhist was 1,082,000, although other estimates
sold for research or educational purposes. This fact       have been between three and four million.
is raising ethical concerns in the medical commu-             Buddhists believe in REINCARNATION or rebirth.
nity, especially among medical schools, which by           They believe that each of us is born again and again
law are not permitted to pay for bodies, nor to sell       in a life cycle. One’s destiny in this life and the next
body parts for financial gain. Because most educa-          is controlled by karmic law, and one accumulates
tional institutions are forbidden from paying, they        good and bad karma through one’s deeds, words,
are concerned that more bodies will go to those            and thoughts. Karma is the law that every cause has
organizations that are permitted to pay, thus leading      an effect, thus our actions have results. Tibetan Bud-
to a shortage of bodies for university medical             dhists believe that the moment of death may actu-
schools. In some states, the demand for body parts         ally lead to enlightenment, or at least to a transition
already outstrips the supply.                              period before the best possible rebirth. Upon death in
    According to an article in The Business Journal of     this world, the spirit enters a place of rest before
Portland, Oregon, “If a body and all its parts are fully   reincarnation in another life. Buddhists do not
marketed, it’s possible to reap more than $200,000,        believe in eternal life in heaven or hell after death.
although few fetch more than $14,000 to $34,000               Powers writes:
from nonprofits.” In an April 2000 series titled “Body
Brokers,” the Orange County Register of California            From its inception, Buddhism has stressed the
reported that brokered body parts will soon fuel an           importance of death, since awareness of death is
estimated $1 billion industry, with the “parts” being         what prompted the Buddha to perceive the ulti-
used for various benefits, from solving bladder trou-          mate futility of worldly concerns and pleasures.
bles to repairing blown-out knees. In 2003 a man              Realizing that death is inevitable for a person who
who supervised the donated-body program at the                is caught up in worldly pleasures and attitudes, he
University of Texas Medical Branch at Galveston               resolved to renounce the world and devote himself
allegedly pocketed more than $18,000 from selling             to finding a solution to this most basic of existential
nails from the fingers and toes of cadavers to a Utah          dilemmas. . . . even today Buddhist teachers
research laboratory, according to a newspaper report.         strongly advise their students to meditate on death
The nails were used to test experimental medicines.           and impermanence, since they are powerful coun-
    In the Business Journal article, Dr. Kamen                teragents to short-sighted concern with the present
Schmidt, head of the Oregon Health and Science                life and one’s own transitory happiness. Buddhist
                                                                                       Buddhism and death 47

  teachers also point out that according to tradition       death. The Buddha’s body was cremated and this set
  Buddha began his teaching career discussing death         the example for many Buddhists, which has con-
  and impermanence in his first sermon on the four           tinued through even to those in the West.
  noble truths, and he also ended his career with               Not all Buddhists are cremated, according to Lin.
  teachings on death and impermanence, which indi-          He writes that some Chinese Buddhists, after the
  cates how important they are in Buddhist teaching         deceased has been buried in a coffin for eight or 10
  and practice.                                             years, will unearth the coffin. Then the bones will
      Tibetan Buddhism places a particularly strong         be gathered in an urn and buried for good.
  emphasis on instructions concerning death, and                Buddhists believe that a person’s state of mind
  Tibetan literature is full of admonitions to be aware     and final thoughts at death are of great importance,
  of the inevitability of death, the preciousness of the    helping determine the condition into which he is
  opportunities that a human birth presents, and the        reborn. Thus when someone is dying in a Buddhist
  great value of mindfulness of death. A person who         home, monks come to offer comfort by reciting
  correctly grasps the inevitability of death becomes       scriptural verses and chanting mantras to them.
  more focused on religious practice, since he or she       Because of this concern for the dying person’s com-
  realizes that death is inevitable, the time of death is   fort of mind, most Buddhists who have been diag-
  uncertain, and so every moment counts.                    nosed as terminal by the medical team in a hospital,
                                                            will be taken home by their families where it is felt
These beliefs are further explained by death and            they will have greater peace of mind among their
bereavement counselor San Filippo:                          family and friends during their final days. Most
                                                            Buddhists agree that the physical body is merely a
  Practitioners of Hinduism and Buddhism believe            shell, and concentrate on the spirit or mind.
  that death should be considered an ‘ever present              Because the state of mind of a dying person is con-
  companion’ in life. They feel the loss of their loved     sidered most crucial to his transcendence or rebirth, it
  one, friend, or associate but they are confident in        is emphasized in Chinese Buddhist culture that one’s
  the dying person’s afterlife. They believe that a per-    final thoughts should be free from worldly attach-
  son is continuously reborn to a new life until the        ments and be directed toward Buddha and Enlight-
  person’s spirit reaches the point of enlightenment        enment. One’s family, relatives, and friends try to
  and all knowing. The Hindus and Buddhists believe         withhold expressions of grief so as not to disturb the
  there are differences in the quality of deaths just as    peace of mind of the dying person; they instead
  there are differences in the quality of births and        attempt to help strengthen the dying person’s Bud-
  lives. Dying is taught as part of his or her religion     dhist aspirations by kind advice and Buddhist practice.
  and culture so that when it is his or her time to die,        Lin writes, “From the Buddhist point of view,
  he or she will die peacefully.                            even when the person is still dying, the conscious-
                                                            ness is still in the process of separating from the
Buddhists believe human life is a life of stress and        body. During this process, it would be very painful if
that the individual who kills himself is destined to        the process is disturbed by movement of the body or
remain in a hundred-year hell and cannot expect             abrupt environmental changes. Hence, it is taught
reincarnation in any form.                                  that the body should not be disturbed in any way for
                                                            at least eight additional hours, preferably until it is
           Funeral Rituals and Mourning                     cold all over. During this dying process, the accom-
Although there are few formal traditions and it is          panying chanting should continue.” The delay and
essentially seen as a non-religious event, the Bud-         chanting help to ease the deceased into the heavens.
dhist funeral is vitally important because it secures           After death, the body is usually washed in a
safe passage of the deceased into the next life. Rit-       bathing ceremony, sometimes led by the male
uals vary according to country, school (Theravada,          members of the family. During this ceremony,
Mahayana, and Vajrayana or Tantric), and type of            friends and relatives pour water over one hand of
Buddhism (e.g., Tibetan, Zen). The early Buddhists          the deceased. After being bathed, the body is sur-
followed the Indian custom of burning the body at           rounded by wreaths, incense, and candles. A photo
48 burial

of the dead person may be placed nearby. The body                 Lin, Yutang. Crossing the Gate of Death in Chinese Buddhist
is never left alone, often staying with relatives until              Culture. Yogichen. Available online. URL: http://www.
it is cremated.                                                      yogichen.org/efiles/mbk16.html. Posted 1995.
    While the dead person is being prepared for cre-              Rinpoche, Sogyal. The Tibetan Book of Living and Dying,
mation, the monks continue to chant in order to                      Revised and Updated. New York: HarperCollins, 2002.
help the dead one’s good energies to be released                  San Filippo, R. David. “Acceptance of Death.” Lutz-San
from their fading personality. The monks then follow                 Filippo Counseling Library. Available online. URL: http://
the family to the funeral, with relatives and friends                www.lutz-sanfilippo.com/library/lsfacceptance
giving food and candles to the monks. Goodwill is                    death.html. Posted April 14, 1991.
created by these gifts and it is believed that the good-
will helps the lingering spirit of the dead person.
    The celebration begins at the funeral, with bell-             burial    The process of disposing of a corpse in a
ringing, gongs, and offerings of incense from family              GRAVE or TOMB. Traditionally, burial has been used to
and friends. Holy texts are chanted and the dead                  denote in-ground interment, although it is some-
remembered with a type of eulogy. The climax of a                 times used for references to BURIAL AT SEA or TREE
Buddhist funeral is the cremation. In countries                   BURIAL (which usually is followed by in-ground bur-
where it is allowed, family and friends may bring                 ial). Some families also choose to bury the ASHES fol-
candles and torches to ignite the bottom of the pyre,             lowing CREMATION. In America today, burial is still
which has been sprinkled with consecrated oil and                 the most common method of laying the dead to rest,
which will consume the corpse. Family may send                    although cremation is growing in popularity. In 2003
material goods along with the deceased to ensure                  Nathan Walton, writing in the environmental maga-
comfort in the next life. Buddhists believe pregnant              zine E, stated that “If laid out head to toe, every per-
women should not attend cremation services, as the                son buried last year in the United States would form
spirit freed from the body might enter the unborn.                a line stretching from Los Angeles to New York City.”
Funeral rites often include ritual meals and may last                 The first evidence of deliberate burial is that of a
for several days.                                                 Neanderthal a little more than 100,000 years ago.
    In the Tibetan Buddhist religious tradition, the              Scientists say this showed the first awareness of
49th day after death represents the culmination of                death, and thus an awareness of self. Anthropolo-
seven weeks of mourning during which the family                   gists have discovered both individual and group
members and friends of the departed come together                 burials, the latter indicating either unsealed pits for
once every week to perform death rites for the ben-               repeated use or the slaying of servants or family
efit of the deceased. On this final day of mourning,                members to accompany the deceased on their after-
Tibetans conduct an elaborate religious ceremony,                 death journeys.
alerting the entire community to reflect upon the                      According to Doctor and Kahn, writing in The
memory of lost ones and offer their prayers so that               Encyclopedia of Phobias, Fears, and Anxieties, second
the deceased may have a peaceful passage into the                 ed. (Facts On File), “Burial customs and rituals indi-
next life.                                                        cate a desire to keep the spirits of the dead away
                                                                  from the living.” Ancient Greeks and Romans
Becker, Carl B. Breaking the Circle: Death and the Afterlife in   believed proper burial was crucial in order for the
   Buddhism. Carbondale: Southern Illinois University             deceased to enter the land of the dead (Romans) or
   Press, 1993.                                                   the afterlife (Greeks). Rural family burial grounds
BuddhaNet: Buddhist Information and Education                     were used in America from the colonial period to
   Network. Available online. URL: http://www.                    the mid-19th century. Western European traditions
   buddhanet.net. Downloaded July 11, 2004.                       dictated that the dead be interred in community
Hopkins, Jeffrey, tr. and ed. His Holiness the Dalai Lama:        burial grounds close to churches. However, the dis-
   Advice on Dying. New York: Atria Books, 2002.                  persal of the American colonial population among
Powers, John. Introduction to Tibetan Buddhism. Ithaca, N.Y.:     scattered farms and plantations may have led to the
   Snow Lion Publications, 1996.                                  use of family burial plots.
                                                                                                    burial at sea 49

   Burials are often preferred over cremation                   drilled in them. Coffinless navy burials in which the
because of family tradition, the need for a place to            flag-draped body slides over the side into the ocean
return to and care for which can give comfort to the            are conducted only in wartime, The ship must be at
survivors, and the permanence of a headstone.                   least three miles from shore and in at least 600 feet
Some feel a burial is more personal, although it                of water.
must be noted that burying cremated ashes can                      The families must pay the cost for military burials
offer some of these same benefits.                               at sea, which varies from negligible to considerable,
   Direction of the body for burial is important for            including shipping the remains to one of five author-
some groups; Muslims, for example, must be placed               ized ports: Norfolk, Virginia; Jacksonville, Florida;
facing Mecca. Similarly, some African Americans                 San Diego; Bremerton, Washington; and Honolulu.
believe it important that the dead be buried feet fac-          Family members are not allowed on board during
ing east, to allow rising at Judgment Day. Otherwise            the service, in which a commemorative flag covers
the person remains in the crossways of the world.               the remains until they are slid into the ocean. Within
   See also AFRICAN AMERICANS AND DEATH; AMERI-                 10 days after the burial, a personal letter is sent to
CAN INDIANS AND DEATH; BURIAL MOUNDS; CEMETER-                  the next of kin, giving the date and time of commit-
IES; DIRECT BURIAL; FUNERAL; HAWAIIAN NATIVE BURIAL             tal and including photographs or video tape of the
CUSTOMS.                                                        ceremony, the commemorative flag, and a chart
                                                                showing where the burial took place.
Colman, Penny. Corpses, Coffins, and Crypts: A History of Bur-      Anyone desiring burial at sea should indicate that
   ial. New York: Henry Holt and Company, 1997.                 preference in writing (in a will or other legal docu-
                                                                ment). During funeral planning, the executor/
                                                                executrix of the estate should contact:
burial at sea    The tradition of burial at sea is an
                                                                Military Medical Support Office (MMSO)
ancient one, with a history as long as that of people
                                                                Mortuary Affairs, Bldg. 38H
going to sea. In earlier times, the body was sewn
                                                                Great Lakes, IL 60085–5200
into a weighted shroud, usually sailcloth. The body
                                                                (800) 876–1131 (toll-free).
was then sent over the side, usually with an appro-
priate religious ceremony. Many burials at sea took                 Many sea burials happen from commercial and
place during World War II when naval forces oper-               charter fishing boats. It is not uncommon for people
ated at sea for months at a time. Since World War II,           who have spent many happy moments fishing or
many service members, veterans, and family mem-                 cruising to alert their families and their charter cap-
bers have chosen to be buried at sea.                           tains that, upon their deaths, they want to be buried
   The U.S. Navy performs approximately 500 sea                 at sea. Most frequently, these will be burials of cre-
burials a year, but only while a navy ship is on offi-           mated ashes, with families along to perform a
cial maneuvers; therefore, a body may remain in                 remembrance ceremony and to scatter the ashes.
storage awhile before it is sent into the sea. Those            Often, the sea burial will be delayed until a special
eligible for a U.S. Navy burial at sea include: active          occasion, such as the birthday of the deceased. Char-
duty, retired, honorably discharged veterans and                ter boats that offer burial at sea may charge $500 for
their family members; U.S. civilian marine person-              a private voyage for a family group of six, or less
nel of Military Sealift Command; and other U.S. cit-            than $200 for an unassisted burial by the captain,
izens who are determined eligible by the Chief of               with a chart that documents the location and time of
Naval Operations because of notable service and/or              the burial service then sent to the family.
other contributions to the U.S. government. Family                  Sea Services Worldwide Maritime Funeral
members and friends usually are not permitted to                Providers has posted on their Web site many pages
attend navy burials at sea.                                     of information on different religious views of burial
   Most at-sea burials by the navy are of cremated              at sea as well as historical references and prayers
remains, but casketed remains may also be buried at             appropriate for sea burials. An example from their
sea. Bodies must be in weighted coffins with holes               Catholic page: “The practice of scattering cremated
50 burial clothes

remains on the sea . . . [is] not the reverent dispo-     • Today, burial clothes may be any favorite item of
sition that the Church requires. The cremated               clothing that the deceased wanted to be buried in.
remains of the body may be properly buried at sea           However, funeral directors state that women are
in the urn, coffin or other container in which they          more frequently buried in a nightgown, a wed-
have been carried to the place of committal. When           ding gown, or a dress suitable for church. The
a body, or the cremated remains of a body are               attire favored by men is a dress suit suitable for
buried at sea, the Committal prayer found at num-           the office or church on Sunday.
ber 406 § 4 is used.”
    Among the celebrities who have chosen burial          Although most people are buried in their own
at sea: John F. Kennedy Jr. (1960–99), Robert             clothes, funeral directors will sell clothes made
Mitchum (1917–97), Ingrid Bergman (1915–85),              specifically for burial. According to Darryl J.
Rock Hudson (1925–85), Steve McQueen (1930–80),           Roberts, author of Profits of Death (Five Star Publi-
Vincent Price (1911–93), L. Ron Hubbard (1911–86),        cations, 1997), “professionally manufactured bur-
Jerry Garcia (1943–95), Janis Joplin (1943–70),           ial clothing is routinely of lower quality (it doesn’t
Dennis Wilson (1944–83).                                  have to survive any washings or dry cleanings!)
                                                          and often is made open in the back in order to
Naval Historical Center. “Naval Ceremony for Burial at    facilitate placing on the body.” In her second book,
   Sea.” Department of the Navy. Available online. URL:   The American Way of Death Revisited (Alfred A.
   http://www.history.navy.mil/faqs/faq85-1.htm. Posted   Knopf, 1998), JESSICA MITFORD rather sarcastically
   July 22, 1999.                                         quotes descriptions of merchandise offered in the
Sea Services. “Religious Views of Death, Cremation and    “Practical Burial Footware” catalog used by funeral
   Burial at Sea.” Sea Services Worldwide Maritime        directors.
   Funeral Providers. Available online. URL: http://
   www.cburial.com/religion_menu.htm. Downloaded
   May 22, 2003.                                          burial methods      Burial methods used worldwide
                                                          over the ages have included discarding corpses,
                                                          interment, tree burial, sea burial, suspended coffins,
burial clothes    Throughout history, ideas about         tombs, vaults, pyramids, grottoes, urns, and crema-
“proper” burial clothing have changed according to        tion. The latest burial method, GREEN BURIALS, is
each culture’s attitudes toward death and have            gaining popularity in Europe.
reflected that culture’s lifestyle.                           By studying the various ways in which societies
                                                          have buried and honored—or failed to honor—their
• The ancient Greeks and Romans opted for expen-          dead, historians learn about a culture’s world views,
  sive and lavish burial clothing.                        social organization, and way of life, according to
• In England, the Enactment of 1678 decreed that          Mike Parker Pearson, author of The Archaeology of
  burial clothes should be of woolen cloth. Linen         Death and Burial (Texas A&M University Press,
  and silk were forbidden.                                2001). In Hawaii, for example, remains of bodies
                                                          uncovered in the last century have revealed a vari-
• Until the 1920s in the United States, appropriate
                                                          ety of burial methods, depending on the island and
  burial clothing for men and women was some-
                                                          the area of burial and on whether the deceased was
  thing in which to “sleep.”
                                                          a commoner or royalty.
• In some Chinese cultures, daughters and daughters-         And burial methods continue to evolve. The
  in-law stitched burial clothes embellished with         Nordic Business Report (June 4, 2001) reports that
  textile art for their parents and parents-in-law to     Swedish biologist Susanne Wiigh-Masak has found
  signify respect for the deceased and to make            an environmentally friendly form of burial that
  them recognizable to their ancestors in the next        quickly recycles corpses into soil enricher. “Wiigh-
  world.                                                  Masak found that cremation emits poisonous gases
• Hindus prefer simple, new, or clean clothing.           with unknown effects while conventional burial
                                                                                            burial places 51

takes between 50 and 60 years for the body to fully       linghouse reports, “In his Notes on the State of Vir-
decompose. In the new method the body is                  ginia, he [Jefferson] concluded that Native Ameri-
immersed in a bath of liquid nitrogen then trans-         cans were wholly capable of constructing these
ferred into a thin, easily degradable coffin.”             monuments and, in particular, the Rivanna mound
                                                          served as a burial place for many generations, a
                                                          place ‘of considerable notoriety among the Indi-
burial mounds       Artificial hills resulting from dirt   ans’.” His determination was notable because
and sand mixed with gravel and piled upon one or          many of that day (and even later) believed Amer-
more corpses. After closing the grave on its occu-        ican burial mounds could not have been con-
pant, soil would be heaped on the stones until it         structed by Indians and instead were evidence of a
took the shape of mounds. In some types of mounds         “lost race” or even the people of Atlantis. But Gar-
there are relatively medium-sized and large stones.       linghouse says, “Today, there is little argument
Many cultures throughout history have used                about the origin of the mounds. Few believe a van-
mounds for burial. Ancient burial mounds are visi-        ished race or mythical beings erected them.
ble in the distance from Stonehenge in southern           Archaeological evidence gathered since 1894 has
England. Some burial mounds are known to be the           firmly established their connection with the Native
tombs of ancient emperors or of members of pow-           North Americans.”
erful clans.
    Many early American Indian tribes buried their        Garlinghouse, Thomas S. “Revisiting the Mound-builder
dead in mounds, and in some cases, a few remain-            Controversy.” History Today 51, no. 9 (September
ing burial mounds are the only proof of certain             2001): 38.
tribes’ existence. They often are the oldest human-
made structures in an area, but many have disap-
peared over the years. At one time, for example,          burial places     Individual and collective burial
thousands of burial mounds dotted the landscape of        places can reflect and represent in important ways
the South Dakota plains, but many hundreds of             the cultural values and practices of the past that
them have been destroyed through farming and              help instruct us about who we are as a people. “Bur-
construction activities.                                  ial places are important because it is on these spots
    Antiquarians in the late 1800s recorded that an       that a people literally becomes one with the land.
Indian burial mound on the East Coast of Florida          They reveal attitudes and reflect both fashion and
near Titusville peaked at 35 feet, was about 200 feet     tradition,” according to Anita Howard, University of
in diameter, and contained human bones and a              Wisconsin at Madison.
piece of coquina (a soft, porous limestone, com-              Perhaps nowhere is this better exemplified than
posed essentially of fragments of shells and coral)       among Native Americans. Joe Bruchac, American
carved in the shape of a turtle. Since then there has     Indian author, explained in a newspaper article (The
been little scientific examination of its contents.        Saratogian, November 11, 2002) that Abenake and
    Garlinghouse writes that ancient tribal burial        Mohawk natives buried their dead on high spots
mounds “are heavily concentrated along major river        because hilltops are closest to the stars, enabling
systems, flood plains, and minor tributaries. An esti-     souls to leave Earth and enjoy happy reunions with
mated 10,000 mounds dot the landscape of the              their ancestors in the heavens.
Ohio Valley, and nearly every major waterway in               And the American Indians were not alone in
Illinois, Indiana, and Missouri is rimmed by clusters     appreciating the importance of a good location for
of mounds.”                                               burial places. During the dot.com golden days, a
    Thomas Jefferson was one of the first to scien-        newspaper reported fierce competition in San Fran-
tifically excavate an American burial mound. He            cisco for water-view burial plots, with prices for a
carefully searched through the layers of a mound          family plot skyrocketing over $100,000.
on his property at Monticello near the Rivanna                Today, most Americans are buried in CEMETERIES,
River in an effort to determine who built it. Gar-        but a couple of generations ago, in the more rural
52 burial rites

landscape, it was common for Americans to be                    Zaslow, Jeffrey. “As More People Remarry, The Family Plot
buried on the family homestead, in an area set aside               Thickens.” The Wall Street Journal, February 20, 2003.
for that purpose. Home funerals and family ceme-
teries were commonplace in America up until the
early 20th century, when professional funeral direc-            burial rites   Rituals associated with burial; most
tors and public cemeteries gradually supplanted the             frequently refers to the customary religious or other
personal rituals.                                               solemn ceremony performed by clergy or funeral
    The need to be buried at home goes back                     professional or family. Military funerals also have
through the ages and across cultures. In ages past, it          their own prescribed rites.
was not unusual for royalty and the gentry (those
most likely to travel) or for soldiers to be returned
home if they died away from their home bases,                   burial-transit permit    The governmental form that
even if that meant bringing back only the bones for             usually accompanies a body to its final disposition.
final burial.                                                    It may be attached to the death certificate or it may
    Even in today’s more urban society, where fam-              be a separate document. Depending on state law, a
ilies tend to be widely dispersed, when the time                burial-transit permit may be issued by the organiza-
comes for a final resting place, the call is likely to be        tion that originates the death certificate, or by a
back home, albeit to a cemetery. For example,                   licensed medical practitioner or medical examiner,
almost 20 percent of the 7,825 people who died in               upon request by a funeral director and after exami-
Collier and Lee counties in southwest Florida in                nation of the dead body. If the dead body is shipped
2001 were transported out of state, according to fig-            by common carrier, the burial-transit permit usually
ures compiled by the Florida Department of Health.              must be enclosed in a strong envelope and attached
The numbers would be even larger were it not for                to the shipping case. These permits provide a way for
the trend today toward more cremations.                         a state to record where final disposition takes place.
    Modern families, along with transportation, have                Burial-transit permits may also provide valuable
created additional burial location challenges. Zaslow           information to historians and genealogists. Morgan
explains, “As multiple marriages and blended fam-               explains: “A transit permit may contain as little
ilies become more common, burial decisions are                  information as the deceased’s name, date of death,
getting more complicated and emotional. The kids                the date of transit, and the destination. Others . . .
often want to reunite mom and dad in death, but                 contain extensive information, including the name
the surviving stepparent has other ideas. About 60              of the physician signing the death certificate, the
percent of states give surviving spouses the right to           date and cause of death, the undertaker and the
make burial decisions, followed by the deceased’s               means of conveyance. These documents could point
adult children, adult grandchildren, parents and sib-           you to the residence of your ancestor in census or
lings. These dilemmas used to be rare but now hap-              land and property records, to mortuary records, or
pen once a week at some funeral homes.”                         to the cemetery where he or she was buried.”
    See also TRANSPORTING HUMAN REMAINS.
                                                                Morgan, George C. “Using Burial Permits as Resources.”
Schmadeke, Steve. “SW Florida’s Largest Air Freight               Available online. URL: http://www.ancestry.com/
   Export? It’s, Well, Bodies . . .” Naples Daily News, March     library/view/columns/george/829.asp?rc=locale%7E&
   31, 2003.                                                      us=0. Posted November 19, 1999.
                                                                                                               C
cachexia      Any general reduction in vitality and                dentists about the anatomy of the body. Among the
strength of body and mind resulting from a debili-                 areas in which cadavers have assisted research are
tating chronic disease; a loss of appetite and pro-                orthopedics and joint reconstruction. In a typical
gressive wasting away due to loss of body fat and                  university, a single cadaver may be used for two
lean body mass (skeletal muscle) that is common in                 years by the anatomy lab, which may have four
terminal illness. This wasting away results in dry                 bodies for use by 24 students at any given time.
and cold skin, as well as hair that falls out easily.                 For many students their first contact with cadav-
Family members may have difficulty observing the                    ers raises many emotions of grief and gratitude, and
decline. The family often responds to the problem by               helps form their attitudes toward death. The Amer-
trying to coax or convince the patient to eat. But                 ican Medical Student Association’s Task Force on
coping with cachexia is not simply a matter of eating              Death and Dying sponsors a project that helps stu-
more. Even if the person wants to eat, even if he or               dents to find ways of expressing these emotions and
she tries to eat, even if the person is given nutrients            to say “good-bye” to their cadavers at the end of a
through a stomach tube or intravenously, the con-                  term—before the cadavers are disposed of in a
dition will not be reversed. Numerous educational                  humane fashion.
interventions are available for patients and families                 With the growing sophistication of computerized
to treat and manage physical and emotional symp-                   images on CD-ROM and the Web, cadavers may
toms associated with cachexia in order to improve                  become less important in the classroom. Some edu-
quality of life. However, these interventions have                 cators say the digital images are more than ade-
not been scientifically validated. Cachexia is one of               quate for the general practitioner’s needs, with
nine ailments approved for medical marijuana usage                 cadavers now needed only for training surgeons
in Oregon. Cachexia may be somewhat acceptable to                  and radiologists, but others insist that only the
patients and families, especially in the final days                actual cadaver provides the necessary kinesthetic
before death. However, it can interfere with func-                 learning and in-depth simulations. In a Newsweek
tioning in the weeks and months before death when                  article, Dr. M. Ashraf Aziz, a Howard University
intervention might prolong independence. Cachexia                  College of Medicine associate, is quoted as saying,
can serve as a prompt for the physician to discuss                 “When the students encounter the cadaver, they
end-of-life issues with the patient.                               are brought in very, very close contact with this
                                                                   [the preciousness of each individual life], and the
Ward, Darrell E. “Coping with Cachexia.” Frontiers 6, no. 3        memories remain over a lifetime.”
  (Spring/Summer 1999).                                               According to the American Association of
                                                                   Anatomists, medical schools across the country
                                                                   have seen cadaver donations rise in recent years as
cadaver    Dead human or animal body usually                       the idea becomes more acceptable, most likely due
intended for dissection by researchers or medical                  to increased knowledge about the procedure and
students. For generations, cadavers have been a pri-               the value to medicine. Some people donate their
mary tool for teaching future doctors, nurses, and                 bodies for use as research cadavers because of special



                                                              53
54 cadaver dogs

feelings for a university; others simply want to make           Canadian Hospice Palliative Care Association
the world a better place.                                       (CHPCA) A nonprofit association whose mem-
   Depending on the medical school, bodies are                  bership is comprised of individuals and hospice/pal-
generally kept for two to three years, often in stor-           liative care programs from all 10 provinces and
age for the first year or so until a new class of stu-           three territories. It provides leadership in hospice
dents starts their studies. Once the students have              palliative care in Canada. Contact information:
finished with the bodies, many schools hold a non-
                                                                Canadian Hospice Palliative Care Association
denominational memorial service and bury the
                                                                Suite 131C
remains—unless the family requests that ashes be
                                                                43 Bruyère Street
returned—in a university memorial garden.
                                                                Ottawa, Ontario K1N 5C8
   In addition to teaching medical students and aid-
                                                                (613) 241–3663 or (800) 668–2785
ing science researchers, cadavers contribute to soci-
                                                                (613) 241–3986 (fax)
ety in other ways. They allow surgeons to learn or
                                                                info@chpca.net
practice face-lift techniques; they perform as car
                                                                http://www.chpca.net
crash testing dummies; and they help investigators
discover causes of airplane crashes.
   See also BODY DONATION; GRAVE ROBBING.                       cannibalism The act or practice of eating the dead
                                                                bodies of one’s own species. Also called necropha-
American Medical Student Association. “Funeral Service          gia. A taboo in modern society, with claims that it
   for Cadavers.” Available online. URL: http://www.            both has and has not existed as a ritual practice,
   amsa.org/dd/cadavers.cfm. Downloaded May 23,                 archaeological research suggests that cannibalism
   2003.                                                        was once practiced by ancient societies in Africa,
Green, Carolyn. “Whole Body Donation.” Medical Post,            North and South America, the South Pacific islands,
   December 5, 2000.                                            and the West Indies. Modern governments and mis-
Jones, D. Gareth. Speaking for the Dead: Cadavers in Biology    sionaries have worked to eradicate any suspected
   and Medicine. Brookfield, Vt.: Ashgate, 2000.                 cultural practices of cannibalism, although isolated
Noonan, David. “Is the Cadaver Dead?” Newsweek, June            cases of it for the purpose of self-preservation have
   24, 2002.                                                    been reported.
Roach, Mary. Stiff: The Curious Lives of Human Cadavers.           Beth A. Conklin, an associate professor of
   New York: W. W. Norton, 2003.                                anthropology at Vanderbilt University who studied
                                                                the Warí natives in the Amazon rainforest, discov-
                                                                ered that at one time the idea of leaving the body of
cadaver dogs     Dogs trained to locate and follow              a loved one in the dirt and letting it rot was as repul-
the scent of decomposing human flesh. They are                   sive to the Warí as the idea of eating human flesh is
used in crime investigation work and in searching               to Americans. Cannibalism was a way for them to
through debris for disaster victims. It was not until           cope with grief and mourning. Salisbury writes:
the late 1970s that handlers realized certain dogs
can be trained to detect human remains long after                  Conklin concluded that the practice was deeply
death, despite burial or attempted concealment.                    rooted in the world view of the Warí and their
Trained dogs are able to distinguish among human                   understanding of how memories affect the grieving
remains, animal remains, and a wide range of other                 process. Like a number of other groups in South
odors that would normally be expected to distract                  America, the Warí have rituals designed to help
them.                                                              bereaved relatives cope with their sorrow by elim-
                                                                   inating things associated with the dead, which pro-
Rebmann, Andrew J., Marcia Koenig, Edward David.                   voke sadness by reminding survivors of their loss
  Cadaver Dog Handbook: Forensic Training and Tactics for the      and also may attract the dead person’s ghost. To
  Recovery of Human Remains. Boca Raton, Fla.: CRC Press,          loosen attachments between the living and the
  2000.                                                            dead, Warí burn all the dead person’s possessions,
                                                                                         capital punishment 55

  including the house he or she lived in. They stop         ship, such as famine or shipwreck, or in cases of
  speaking the person’s name and change the appear-         “pathological lunatics,” such as Jeffrey Dahmer.
  ance of the village and other places where the dead
  person spent time.                                        Hodgkinson, Thomas. “The Essay: Cannibalism: A Potted
      “Consuming the body is part of this process as           History.” Independent, March 17, 2001.
  well,” Conklin says. “Far more than we do, the            Salisbury, David F. “Giving Cannibalism a Human
  Warí see the body as a place where personality and           Face.” Exploration, Vanderbilt University. Available
  individuality reside, and so, of all the things that         online. URL: http://exploration.vanderbilt.edu/news/
  remind you of dead people, the corpse is the                 news_cannibalism_nsv.htm. Posted August 15, 2001.
  strongest reminder. So they believed it was impor-
  tant to transform the corpse in order to help trans-
  form survivors’ memories of their dead relative.”         capacity     In relation to end-of-life medical care, the
  This transformation involves developing new               ability of the patient to understand, weigh, reason,
  images of the dead person joining the animal world.       and appreciate the nature and consequences of
  According to their traditional beliefs, the spirits of    health care decisions and to make an informed deci-
  dead relatives go to an underground world from            sion about the risk and benefit of available treatment
  which they return in the form of wild, pig-like ani-      options. Capacity requires that the person be able to
  mals called peccaries that are a major source of          comprehend his options, weigh those options and
  meat for the Warí. The ancestor-peccaries seek out        balance the positives and negatives, and then make a
  hunters from their own families and offer them-           decision that coherently expresses his own values in
  selves to be shot, ensuring that their meat will go to    relation to the options. The patient’s ability to under-
  feed the people they love.                                stand other unrelated concepts is not relevant.
      This special relationship with peccaries is part of   Capacity is sometimes referred to as COMPETENCY, but
  a native cosmology centered on ideas about com-           it is not the same. Competency is a legal status
  munication and transformations between humans             imposed by the court. ADVANCE DIRECTIVES allow the
  and animals. According to Conklin, the traditional        patient to establish values and treatment preferences
  mourning rites of the Warí emphasized helping sur-        to be honored in the future when competency or
  vivors to gradually stop dwelling on memories of          capacity has lapsed. Capacity may also be considered
  the past and develop new images of the dead reju-         when health care professionals determine whether or
  venated as animals who feed the living. Eating the        not to withhold the prognosis from dying patients.
  body at funerals affirmed these positive religious
  ideas. Reconsidering the range of meanings that
  consuming substances from the human body had              capital punishment The use of execution as the
  for people in the past is important, Conklin says,        consequence for a crime. In 2002, 71 persons in 13
  because it challenges the negative stereotypes of         states were executed—33 in Texas; seven in Okla-
  cannibalism that have often been used to denigrate        homa, six in Missouri; four each in Georgia and Vir-
  and stigmatize native peoples.                            ginia; three each in Florida, South Carolina, and
                                                            Ohio; two each in Alabama, Mississippi, and North
Other anthropologists since the 1970s have denied           Carolina; and one each in Louisiana and California.
that cannibalism as a ritualistic behavior has ever         This was five more than in 2001. Of those persons
actually taken place. The skeptics have produced            executed in 2002, 53 were white and 18 were black;
alternative explanations for what has been offered          69 were men and two were women. Lethal injection
as evidence of cultural cannibalism. These explana-         accounted for 70 of the executions; one was carried
tions have included isolated survivalism, false             out by electrocution. Thirty-eight states and the fed-
reports due to cultural slander, and invented reports       eral government in 2001 had capital punishment
by Europeans during the Spanish Inquisition in              statutes.
order to feel superior to other cultures. All agree            Capital punishment has long been a controver-
that men have eaten men in times of extreme hard-           sial issue—proponents say it deters crime and saves
56 capital punishment

governments money; opponents have moral con-               (1,667) than had in any previous decade. By the
cerns or argue that every penal system is subject to       1960s, all but 10 states had capital punishment
error and arbitrariness, or that the social resources      offenses, but opposition against it was growing, with
expended on capital punishment have outrun its             an unofficial moratorium being instituted in 1967.
benefits. The United States is the only Western            No executions occurred for 10 years until convicted
nation to still impose capital punishment, with 75         murderer Gary Gilmore was executed by firing
countries (as of March 2001) abolishing it, includ-        squad in Utah in 1977.
ing those in the European Union. A few countries              In 1974 a majority of Roman Catholic bishops
have retained it for treason and war crimes.               went on record opposing capital punishment. Then
   Native American tribes have long opposed the            in 1980 they presented a more detailed statement
death penalty, refusing to allow tribal members to         outlining their reasons for opposing the death
face capital punishment. Federal prosecutors handle        penalty. But they acknowledged that a position sup-
serious crimes on American Indian reservations but         porting the use of capital punishment is not incom-
cannot seek the death penalty unless tribes sign an        patible with Catholic tradition. While most bishops,
accord allowing members to face execution. But in          consistent with pastoral statements, oppose the
2003, following several high-profile murders and an         death penalty, 19 percent say they do favor the
alarming increase in crime on Navajo land, the Navajo      “death penalty for first degree murderers.”
Nation president said he now supports the death               During the 1990s more countries abolished capi-
penalty for especially violent murders on the reser-       tal punishment, Canada in 1998. In the United
vation and also supports planned public hearings           States, the debate continued; in 2002, the Supreme
to reconsider the tribe’s long-held opposition. Sup-       Court overturned the death sentences of dozens of
port today among the Navajos is evenly divided,            convicted murderers, ruling that the death penalty
largely because many younger people do not view            must be imposed by juries and not judges. Today,
tradition as a reason to withhold the death penalty.       those opposed to capital punishment are becoming
                                                           even more vocal as DNA tests prove that many peo-
            History of Capital Punishment                  ple have been falsely convicted of capital punish-
Capital punishment has been used since ancient             ment crimes such as rape and even murder. Since
times, and was practiced throughout Western                1973 more than 100 people have been released from
Europe from the fall of the Roman Empire until             death row after evidence of their innocence was
recently. The first capital punishment statutes in the      uncovered.
New World were instituted in the Massachusetts                Michael Conlon, writing for the Reuters news
Bay Colony in 1636, and could be applied to idola-         agency in July 2003, noted that a quiet change may
try, witchcraft, blasphemy, murder, assault, sodomy,       be taking effect in the middle of the noisy debate
adultery, rape, perjury, and rebellion. Fifty years        over capital punishment: “The number of new
later, William Penn restricted capital punishment to       death penalty sentences being imposed each year
murder and treason.                                        has dropped by nearly half.” Reasons cited for the
    The first protestations in the United States against   decline have included reluctance by juries fearful of
capital punishment were credited to a Dr. Benjamin         putting innocent persons to death, increasing costs
Rush, who urged Benjamin Franklin, among others,           of death penalty trials, and the minefield of legal
to develop a penal system that would rehabilitate          challenges that can get prosecutors reversed.
offenders rather than kill them. Internationally,
Cesare Beccaria’s Essay on Crimes and Punishment in        Banner, Stuart. “The Death Penalty’s Strange Career.” The
1764 was among the earliest writings against capi-            Wilson Quarterly 26, no. 2 (April 1, 2002): 70.
tal punishment.                                            DeFalco, Beth. “Navajo President Backs Death Penalty.”
    On March 1, 1847, Michigan became the first                Associated Press, June 6, 2003.
English-speaking territory in the world to abolish         Gelin, Richard J. Politics and Religious Authority: American
capital punishment, but other states continued it.            Catholics since the Second Vatican Council. Westport,
During the 1930s, more executions occurred                    Conn.: Greenwood Press, 1994.
                                                                                           caregiver burnout 57

caregiver     In the context of end-of-life care, a        devastating impact of watching patients die. Wat-
caregiver most often refers to the adult child, sibling,   stein writes, “It is not surprising that emotional
spouse, partner, or parent who is responsible for          responses to these stresses—sometimes referred to
and attends to the personal needs of the dying indi-       as ‘bereavement overload’ or ‘chronic mourning‘—
vidual in the home. In a few cases, the caregiver          should affect them.
may be a long-time neighbor or friend, or it may be            “The effects of burnout are both personal and
a volunteer. The term caregiver is also used for           institutional. Burned out caregivers may experience
physicians, nurses, therapists, or social workers who      difficulty functioning, psychological distress, and
work with long-term patients. Many available pro-          poor health. Where the rate of staff burnout is high,
grams that deal with the terminally ill person at          institutions suffer low morale, communication
home require a designated caregiver to ensure              breakdown, internal conflict, decreased productiv-
proper care for the patient, and may deny care if          ity, absenteeism, and high turnover.
there is not such a person. In addition to paid pro-           “Strategies to address burnout include creating
fessional caregivers, there are over 23 million            formal and informal support groups, developing cop-
unpaid caregivers in America, according to the New         ing and stress management skills, and providing pro-
Jersey Comfort Care Coalition.                             fessional development opportunities. All help
   From their random sample survey, the National           individuals bolster or renew their inner resources.
Family Caregivers Association (NFGA) determined            Institutional responses can also support both patients
that more than one-quarter (26.6 percent) of the           and staff, without requiring the costly overhaul of
adult population—or more than 50 million peo-              established systems. Such institutional responses
ple—provide care for a chronically ill, disabled, or       include restructuring workloads, benefits and time
aged family member or friend during a single year.         schedules, improving communication at all levels,
   The NFGA also has found that caregiving is no           and acknowledging the difficulties facing staff.”
longer predominantly a woman’s responsibility.                 Caregiving can consume every moment of the
Men now make up 44 percent of the caregiving               in-home caregiver’s time. Even in wealthy house-
population, according to NFGA’s survey in 2000.            holds, caregivers need help. Depression, exhaus-
Estimates three years prior to that put men at only        tion, money worries, and fears for the future often
27 percent. But there are some differences between         trouble both the recipient of the care and the care-
women and men caregivers. A 2001 AARP study of             giver. Studies have found that a caregiver who is
baby boomer caregivers found men tend to spend             under mental or emotional strain is at increased
less time than women talking to a loved one’s doc-         risk for illness and premature death. According to a
tors, hiring aides, and helping with personal care.        study in the December 15, 1999, issue of the Jour-
On the other hand, they match women in shopping            nal of the American Medical Association, elderly care-
and running errands and handling paperwork. Men            givers with a history of chronic illness themselves
surpass female caregivers in doing home repairs.           who are experiencing caregiving related stress have
Edgar writes that male caregivers often encounter          a 63 percent higher mortality rate than their non-
biases, even among nurses and health care aides.           caregiving peers.
                                                               Scannell warns, “Our hidden epidemic of care-
Edgar, Julie. “Caregiving’s Changing Face.” Detroit Free   giver stress is likely to expand as the population of
  Press, December 5, 2002.                                 baby boomers ages. Already, nearly one out of every
                                                           four households is involved in caregiving for persons
                                                           aged 50 or over, according to the National Alliance
caregiver burnout      A condition resulting from          for Caregiving.”
chronic stress, characterized by physical and emo-
tional exhaustion and sometimes physical illness.          Family Caregiver Alliance. “Taking Care of YOU: Self-Care
End-of-life caregivers, both professionals and fam-          for Family Caregivers.” Family Caregiver Alliance. Avail-
ily, face unique demands and stresses. All must cope         able online. URL: http://www.caregiver.org/factsheets/
daily with complex ethical and legal issues and the          taking_care_of_you.htm. Downloaded May 28, 2003.
58 Carlson, Lisa

Scannell, Kate. “Hidden Patients—Strain Takes Major Toll         Traditionally, caskets have been sold only by
   on Family Caregivers.” Alameda (Cal.) Times-Star, July    funeral homes. But with increasing frequency,
   20, 2003.                                                 showrooms and Web sites operated by third-party
Watstein, Sarah Barbara. “Burnout and AIDS,” in The          dealers are selling caskets. You can buy a casket
   AIDS Dictionary. New York: Facts On File, 1998.           from one of these dealers and have it shipped
                                                             directly to the funeral home. The Funeral Rule
                                                             requires funeral homes to agree to use a casket you
Carlson, Lisa     Author of Caring for the Dead: Your        bought elsewhere, and does not allow them to
Final Act of Love, published in 1998, which covers           charge you a fee for using it.
rights and options for dealing with death-care                   No matter where or when you are buying a cas-
providers and is generally considered the bible of           ket, it is important to remember that its purpose is
personal burial practices. Carlson has helped con-           to provide a dignified way to move the body before
sumers to understand their rights and avoid                  burial or cremation. No casket, regardless of its qual-
exploitation by the funeral industry at a vulnerable         ities or cost, will preserve a body forever. Metal cas-
time in their lives. She also lobbies for reform of fed-     kets frequently are described as “gasketed,”
eral and state laws and regulations and more rigor-          “protective,” or “sealer” caskets. These terms mean
ous enforcement of existing protections.                     that the casket has a rubber gasket or some other
                                                             feature that is designed to delay the penetration of
                                                             water into the casket and prevent rust. The Funeral
casket Oblong box or chest in which a corpse or its          Rule forbids claims that these features help preserve
remains are buried or cremated. Also called COFFIN.          the remains indefinitely because they don’t. They
Casket is the term used by the American funeral              only add to the cost of the casket. Airtight and
industry; coffin is used in Great Britain. A casket           watertight caskets do not prevent decomposition.
often is the single most expensive item in a tradi-          However, if you will be shipping the body to
tional, full-service funeral. Caskets vary widely in         another country, it is important to note that some
style and price and are sold primarily for their visual      countries require that the remains be shipped in a
appeal. Typically, they’re constructed of metal,             sealed casket.
wood, fiberboard, fiberglass, or plastic. Although an              Most metal caskets are made from rolled steel of
average casket costs slightly more than $2,000, some         varying gauges—the lower the gauge, the thicker
mahogany, bronze, or copper caskets sell for as much         the steel. Some metal caskets come with a warranty
as $10,000. There are lower cost alternatives, such as       for longevity. Wooden caskets generally are not gas-
rental of a casket for viewing purposes only.                keted and don’t have a warranty for longevity. They
                                                             can be hardwood like mahogany, walnut, cherry,
                   Selecting a Casket                        or oak, or softwood like pine. Pine caskets are a
When you visit a funeral home or showroom to                 less expensive option, but funeral homes rarely
shop for a casket, the FUNERAL RULE requires the             display them. Manufacturers of both wooden and
funeral director to show you a list of caskets the           metal caskets usually warrant workmanship and
company sells, with descriptions and prices, before          materials.
showing you the caskets. Industry studies show that
the average casket shopper buys one of the first                            Caskets for Cremations
three models shown, generally the middle-priced              Many families that opt to have their loved ones cre-
of the three.                                                mated rent caskets from the funeral home for the
    For this reason, it’s in the seller’s best interest to   visitation and funeral, eliminating the cost of buy-
start out by showing you higher-end models. If you           ing a casket. For those who choose a direct crema-
haven’t seen some of the lower-priced models on              tion without a viewing or other ceremony where
the price list, ask to see them, but don’t be surprised      the body is present, the funeral provider must offer
if they’re not prominently displayed, or not on dis-         an inexpensive, unfinished wood box or ALTERNA-
play at all.                                                 TIVE CONTAINER that is cremated with the body.
                                                                                              catacombs 59

Under the Funeral Rule, funeral directors who offer      catacombs connected with the two chief Jewish
direct cremations may not tell you that state or local   colonies, and some smaller ones, also existed.
laws require a casket for direct cremations, because         Because the later Christians were regarded as a
none do.                                                 sect of the Jews, those Jews who were converted by
                                                         the Apostles at Rome were buried in the catacombs
               Special-interest Caskets                  of their fellow countrymen. Historians write that
In recent years, personalized “art caskets” have         Christian converts of highest rank had their own
come into vogue. Some critics see special-interest       tombs and permitted their fellow Christians to con-
caskets as classic expressions of baby-boomer self-      struct, in connection with these family tombs, places
absorption and have called them unseemly, but that       of burial modeled on the Jewish catacombs. Each
has not stopped this sub-industry from blossoming.       catacomb would bear the name of its original fam-
Having a personalized casket has been referred to as     ily, or of the martyr who formed its nucleus. Over
the ultimate final statement.                             the course of 300 years some 50 catacombs, large
   One Dallas art casket firm has decorated caskets       and small, formed a wide circle around the city, the
with images such as Our Lady of Guadalupe,               majority being about half an hour’s walk from the
cherubs, the Kiss rock group, Gone Fishing scene,        city gate.
and AIDS awareness ribbons. For the golf fanatic,            According to The Catholic Encyclopedia, “The early
there’s a Fairway to Heaven casket; for the NASCAR       Christian name for these places of burial was koime-
fan, a casket with a checkered flag and the motto,        terion, coemeterium, place of rest. When, in the
“The Race Is Over.” Those with an irreverent sense       Middle Ages, the recollection of the catacombs
of humor can choose the coffin that appears to be a       passed away, the monks attached to the church of
brown paper parcel stamped with bright red letters:      St. Sebastian on the Via Appia kept the ‘coeme-
“Return to Sender.” The company offers nearly 40         terium ad catacumbas’ on this road accessible for
designs and sells 2,500 a year, at an average cost of    pilgrims. After the rediscovery and opening of the
$3,000.                                                  other coemeteria, the name belonging to this one
   To fill growing orders for personalized caskets,       coemeterium was applied to all.”
Batesville Casket Company, the largest casket build-         Roman catacombs were used as hiding places
ing firm in the United States, in 1997 redesigned its     from persecution, as shrines to saints and martyrs,
production and distribution processes based on just-     and for memorial services as well as for interment of
in-time manufacturing methods. They fill special          the dead. Some of the catacombs were built on four
orders ranging from unusual fabric for a casket’s        levels, connecting an enormous system of galleries
lining to an uncommon match between a particular         and linking passages with steep, narrow steps. Bod-
exterior treatment and the interior decor, to cus-       ies of the deceased were placed in niches, 16 to 24
tomized engraving of casket lids.                        inches high by 47 to 59 inches long, cut from the
                                                         wall of soft volcanic rock. The bodies were fully
                                                         clothed, wrapped in linen, sprinkled with ointments
catacombs     Underground tunnels or cemeteries,         to offset the decaying odor, and sealed with a slab
with recessed chambers where bodies are buried.          inscribed with the name of the deceased, date of
Prior to Christianity, Romans practiced cremation.       death, and a religious symbol. The number of graves
Catacombs were outside the walls of the city, as         in the Roman catacombs is estimated at two million,
burial of bodies within the precincts of Rome was        with guesses that if placed in a straight line they
forbidden. The first catacombs were burial places        would extend the length of Italy. They comprise a
for the Jews living in Rome, who retained their          space of more than 600 acres. The inscriptions,
native method of burial, and imitated the rock-          paintings, graffiti, and other artifacts discovered
graves of Palestine by laying out cemeteries in the      within the catacombs have aided historians in their
stonelike stratum of tufa around Rome. Jewish            studies of early Christianity. Once Christianity was
catacombs were laid out and developed before             established as the official religion of the Roman
Christianity appeared in Rome. Two large Jewish          Empire, aboveground cemeteries became the custom.
60 catafalque

When invading tribes began plundering the cata-           such peacetime disasters as hurricanes, explosions,
combs, the popes began transferring the martyrs’          fires, floods, and earthquakes.
bones to churches and filled in the entrances to the
catacombs. They were forgotten until rediscovered
by accident in the 1500s. A few small catacombs           Catholicism and death       In the Roman Catholic
exist outside Rome, notably at Naples, on Sicily,         Church, the body is usually prepared for burial by
Malta, and Sardinia, and in North Africa.                 embalming; this is followed by a requiem Mass and
                                                          burial, with visitation prior to the funeral. Addi-
The Catholic Encyclopedia, Volume 3. “Roman Catacombs.”   tional masses may be conducted periodically over
   Available online. URL: http://www.newadvent.org/       the next year. Catholic burial rites are presented by
   cathen/03417b.htm. Updated April 20, 2003.             the church’s Order of Christian Funerals, stating,
                                                          “The Church’s belief in the sacredness of the human
                                                          body and the resurrection of the dead has tradi-
catafalque A decorated BIER on which the coffin            tionally found expression in the care taken to pre-
rests in state during a funeral. Also known as a cas-     pare the bodies of the deceased for burial.”
ket standard. Catafalques are used to commemorate            The Order of Christian Funerals, a revision and
the death of high-ranking officials and heads of          adaptation of the Rite of Funerals, became effective
state. From the 14th through the 16th centuries,          in the United States on November 2, 1989. It gives
catafalques were lavishly decorated with fabrics and      three types of funeral celebration, corresponding to
ornaments. According to the Grove Dictionary of Art,      the three places in which they are conducted (the
historical catafalques were “the visual and theolog-      home, the church, and the cemetery) and according
ical focal point of elaborate obsequies involving         to the importance attached to them by the family,
prayers, orations, a requiem mass and absolution          local customs, the culture, and popular piety. This
rites. Their architectural forms and profuse decora-      order of celebration comprises the following princi-
tion permitted complex iconographic programs that         pal elements:
glorified the deceased.”
                                                          • The first element of the funeral rites is the Vigil or
                                                            Wake service, which is celebrated in the funeral
catafalque party Australian military honor guard            home in the presence of family and friends, and
mounted over a catafalque during a period of lying          held in either the afternoon or the evening.
in state, during a military funeral in a church, at a     • The Funeral Mass is usually celebrated in the
memorial or special occasion, or during a memorial          morning, and may begin outside the church
service in a church for a recently deceased distin-         entrance, with the body of the deceased being first
guished personage. A catafalque party consists of           blessed with holy water, evoking the baptism. This
four sentries, a waiting member in reserve, and a           is followed by the placing of the funeral pall, a
commander. If a catafalque party is requested to be         large white cloth, on the casket. Both the sprin-
mounted for an extended period, for example dur-            kling with water and the placing of the pall remind
ing a lying in state, then a series of watches is           the faithful of the Baptism in which the person
divided into vigil periods. A catafalque party must         has already died and been raised with Christ.
not be senior in rank to the deceased over whom it        • The final station of the funeral liturgy is the Rite
is mounted. Legend has it that the first catafalque          of Committal at the grave site, with the parish
parties guarded important and wealthy people’s              priest, deacon, or pastoral associate accompany-
coffins from thieves and vandals.                            ing the family and friends to the cemetery.

                                                          Catholics pray for the dead, asking God to take that
catastrophic death   An actuarial term used to            person’s soul into heaven. Clark explains that those
denote a concentration of insurance claims from           prayers begin even before death, when priests per-
                                                                                               cause of death 61

form the sacrament known as the Last Rites by giv-            cause of death The injury or disease that results
ing communion—called Viaticum—to the person                   in physical trauma to the body, leading to death.
for the last time, which means, literally, “food for          Oftentimes, death may be a result of multiple
the journey.”                                                 causes. For example, someone might have cancer,
    Although at one time the Catholic Church did              but the direct cause of death will be pneumonia. In
not permit cremation, the rule has changed in                 recent years, the United States has seen a dramatic
modern times but with caveats. “While cremation               shift from the majority of the causes of death being
is now permitted,” the Order of Christian Funerals            due to infectious disease to being due to chronic
states, “it does not enjoy the same value as burial           disease, largely as a result of advances in treatment
of the body . . . the church clearly prefers and              and technology.
urges that the body of the deceased be present for               Most state laws require the physician in charge of
the funeral rites, since the presence of the human            the care of the patient for the illness or condition
body better expresses the value which the church              that resulted in death to complete the medical certi-
affirms in its rites. However, when extraordinary             fication section on the DEATH CERTIFICATE. The physi-
circumstances make the cremation of a body the                cian is requested to state the diseases or conditions
only feasible choice, pastoral sensitivity must be            that caused the death and other significant condi-
exercised by all who minister to the family of the            tions contributing to death. If a death occurs with no
deceased.”                                                    physician in charge of the care, the county coroner
    The diocese of St. Petersburg, Florida, offers a          or the medical examiner may be responsible for
“hierarchy” of sorts for Catholic funerals. It lists in       determining the cause of death, either at the scene
order of preference those practices deemed accept-            or during a subsequent autopsy. Several causes of
able by the Catholic Church for funeral liturgies:            death are typically listed on death certificates of eld-
First Preference, funeral rites with the body present;        erly decedents. These are termed the “multiple cause
Second Preference, funeral rites with the body pres-          of death” listings and are routinely recorded in U.S.
ent and cremation afterward; Third Preference,                national data files prepared annually by the National
funeral rites with the cremated remains present. So           Center for Health Statistics (NCHS). Increasingly,
while permitted, cremation is still uncommon for              death is due not to one single disease but to a com-
Catholics.                                                    plex set of interacting pathological processes.
    The Catholic Church does not allow cremated                  In recent years, several organizations, such as
remains to be scattered or kept in a home. The dio-           the National Institutes of Health, the American
cese of St. Petersburg explains the rationale for this:       Medical Association, and the American Academy
“The Church believes cremated remains of a body               of Family Physicians, have expressed concern about
should be treated with the same respect given the             the number of inaccurate and incomplete listings of
human body from which they come. If cremated                  cause of death being put on death certificates. Stud-
remains are not treated with honor and dignity, cre-          ies bear out their concern, as explained by Woods:
mation can allow for disrespect of the human body.            “One analysis of 494 death certificates found that
Scattering the ashes deprives loved ones and                  more than 40 percent were improperly completed.
descendants of the opportunity to visit the remains           Another found that not a single death certificate
where they can pray and reflect upon the life and              out of 69 studied listed the correct underlying cause
memory of the deceased. Dividing the cremated                 of death.” Accurate and full information regarding
remains among family and friends or keeping them              cause of death is vitally important, because govern-
in the home seems to diminish the respect for                 ment officials use the data in deciding what to spend
human life and shows a lack of proper respect and             on research for individual diseases.
dignity for the dead.”                                           For tabulation purposes, causes of death are
    See also CAPITAL PUNISHMENT; PURGATORY.                   coded according to the International Classification of
                                                              Diseases (ICD), which provides the essential ground
Clarke, Elizabeth. “How Different Religions Handle Death      rules for the coding and classification of cause-of-
   of Faith and Forever.” Palm Beach Post, January 4, 2002.   death data. The ICD was developed collaboratively
62 celebration days

between the World Health Organization (WHO) and                religious ritual connected to the event, you might
10 international centers, one of which is housed at            suggest they attend that portion and not attend
the National Center for Health Statistics. The pur-            the “celebration.”
pose of the ICD is to promote international compa-           • Try making a plan for the days, but know that
rability in the collection, classification, processing,         you can change your mind and do something dif-
and presentation of health statistics. The United              ferent.
States is required to use the ICD under an agree-
                                                             • Bringing up the subject of celebrations after losing
ment with WHO that has the force of an interna-
                                                               a loved one can be hard but it is essential. If you
tional treaty.
                                                               do not do this, individual family members may be
   The ICD has been revised approximately once
                                                               operating on different assumptions that could
every 10 years to stay abreast with advances in
                                                               result in misunderstandings. Discuss ways to add
medical science and to ensure the international
                                                               a new element to celebrations or start a new tra-
comparability of health statistics. The 10th and most
                                                               dition. Communicating each other’s thoughts and
recent revision, known as the ICD-10, was first used
                                                               concerns is vital to prevent those misunderstand-
to classify deaths that occurred on January 1, 1999,
                                                               ings and hurt feelings.
and after. The previous version, the ICD-9, was used
from 1979 through 1998. The ICD-10 is much more              • Include the memory of their loved one in some
detailed, with about 8,000 possible categories for             way (like lighting a candle for them). After the
cause of death compared with 4,000 categories in               event, talk openly about how it went and plan
the previous version.                                          any necessary changes for the next time.

Stallard, Eric. “Underlying and Multiple Cause Mortality     For any traditional celebrations following the loss of
   at Advanced Ages: United States 1980–1998.” North         someone important to that celebration, you will
   American Actuarial Journal 6, no. 3 (July 2002): 64–87.   want to continually ask yourself if you are follow-
Woods, Michael. “Causes of Death Need to Be More Accu-       ing the tradition because you enjoy it, or because
   rate.” Toledo Blade, November 20, 2002.                   you feel it is something you “must do” or is it being
                                                             done simply because “it has always been done that
                                                             way”; and if so, what would be the issues if you
celebration days      Holidays, anniversaries, birth-        changed or even eliminated the traditions.
days, and other personal family events can be very              See also ANNIVERSARY REACTION.
difficult, especially during the first year following
the loss of a family member. It can take several years       American Association of Retired Persons. “Helping Others
before a date that is particularly relevant to the             Through Celebration Days.” Available online. URL:
deceased can be celebrated without renewed feel-               http://www.aarp.org/griefandloss/articles/44_a.html.
ings of grief and sadness. Grief counselors suggest            Downloaded June 2, 2003.
planning ahead as to the best ways of celebrating
these days. Some people choose to make changes in
the way they celebrate special days. Others decide to        cemeteries     Tracts of land set aside for interment
observe these occasions as they did before, but often        of the dead; they may be either private or public.
they cannot follow the usual traditions, and the loss        Federal, state, and local governments all have roles
of the absent person will be especially noticed. The         in regulating and overseeing funeral homes and
AARP Grief Program offers suggestions for helping            cemeteries. Commercial cemeteries are regulated
others through celebration days:                             primarily at the state or local level. Cemeteries are
                                                             regulated by state boards as well as other agencies,
• Social and family gatherings can be overwhelm-             including offices of attorneys general and depart-
  ing and seeing people is painful. It feels like there      ments of health and insurance.
  is nothing to celebrate when you are in tremen-               The concept of commercial cemeteries was born
  dous pain. Some family members particularly                in the 20th century, the brainchild of Hubert Eaton,
  affected may choose not to attend. If there is a           who took over a rundown cemetery called Forest
                                                                                                 cemeteries 63

Lawn in Glendale, California, and built it into For-       ies, such as religious and municipal cemeteries,
est Lawn Memorial Park (the first cemetery to be            were exempt from state regulation. Oversight of
called a memorial park), which has grown to five            cemeteries is conducted primarily at the state or
locations in Greater Los Angeles, with a total of          local level. The Federal Trade Commission’s (FTC)
around 1,500 acres—and a Forest Lawn “brand”               Funeral Rule applies only to certain cemeteries that
that appears throughout the country.                       sell both funeral goods and services.
    The earliest cemeteries in America were in                The FTC offers the following suggestions and
churchyards, and thus prominently situated in the          warnings when considering cemetery choices:
heart of the community. In the 19th century, when
church graveyards began to fill up, health codes and        • When you are purchasing a cemetery plot, con-
zoning restricted new graveyards to less valuable            sider the location of the cemetery and whether it
locations, pushing them to the outer edges of town           meets the requirements of your family’s religion.
limits, but still usually owned and maintained by            Other considerations include what, if any, restric-
the town. In The American Way of Death Revisited             tions the cemetery places on burial vaults pur-
(Alfred A. Knopf, 1998) JESSICA MITFORD writes,              chased elsewhere, the type of monuments or
“Whether owned by church or municipality, the                memorials it allows, and whether flowers or
burial ground was considered a community facility;           other remembrances may be placed on graves.
charges for graves were nominal, and the burial            • Cemetery plots can be expensive, especially in
ground was generally not expected to show a                  metropolitan areas. Most, but not all, cemeteries
profit.” Today’s commercial cemeteries sell not only          require you to purchase a grave liner, which will
burial space; they also charge for such extras as per-       cost several hundred dollars. Note that there are
petual care, vaults, grave markers, flowers, statuary,        charges—usually hundreds of dollars—to open a
and more. Thus, the cemetery can end up being the            grave for interment and additional charges to fill
greatest of all final expenses.                               it in. Perpetual care on a cemetery plot some-
    In a September 1999 report to Congress, the              times is included in the purchase price, but it’s
Government Accounting Office illustrated how                 important to clarify that point before you buy the
diverse states are in protecting consumers in their          site or service. If it’s not included, look for a sep-
death care transactions, using California, Florida,          arate endowment care fee for maintenance and
Maryland, New York, and Texas as examples. These             grounds keeping.
five states differed in their approaches to regulation
                                                           • If you plan to bury your loved one’s cremated
and oversight of those cemeteries within their juris-
                                                             remains in a mausoleum or columbarium, you can
dictions, such as nonreligious, for-profit cemeteries.
                                                             expect to purchase a crypt and pay opening and
For example, in Maryland the office with regulatory
responsibility for cemeteries was administered by a          closing fees, as well as charges for endowment care
single individual with the authority to perform the          and other services. The FTC’s Funeral Rule does
numerous functions of the office. In New York                not cover cemeteries and mausoleums unless they
cemeteries were regulated by a board consisting of           sell both funeral goods and funeral services, so be
the secretary of state, the attorney general, and the        cautious in making your purchase to ensure that
commissioner of health. The selected states also dif-        you receive all pertinent price and other informa-
fered in terms of the requirements and restrictions          tion, and that you’re being dealt with fairly.
placed on cemeteries, including restrictions on what       • All veterans are entitled to a free burial in a
goods and services cemeteries could sell. In addition,       national cemetery, along with a grave marker.
New York was unique among the five states in that             This eligibility also extends to some civilians who
it required that cemeteries under its jurisdiction be        have provided military-related service and some
operated on a not-for-profit basis.                           Public Health Service personnel. Spouses and
    In each of the selected states, the state regulatory     dependent children also are entitled to a lot and
agencies responsible for cemeteries had jurisdiction         marker when buried in a national cemetery. There
over only a fraction of the total number of ceme-            are no charges for opening or closing the grave,
teries in the state because certain types of cemeter-        for a vault or liner, or for setting the marker in a
64 charitable gifting

  national cemetery. The family generally is respon-        In Tokyo, cemetery plots are selling for as much
  sible for other expenses, including transportation     as $86,800 (40-square-feet in size). In July 2003,
  to the cemetery. For more information, visit the       the city government began taking applications for
  Department of Veterans Affairs Web site at             50 newly opened spots at the famous Aoyama
  www.cem.va.gov. To reach the regional VA office         Cemetery—the first such sale in 43 years. Smaller
  in your area, call (800) 827–1000.                     plots there start at $30,000.
• In addition, many states have established state           In the United States, land value and scarcity is
  veterans cemeteries. Eligibility requirements and      also beginning to play an important role for the
  other details vary. Contact your state for more        future of cemeteries. In Vail, Colorado, for example,
  information.                                           several efforts to build a cemetery have been
                                                         defeated, with opponents saying there was not
• Beware of commercial cemeteries that advertise
                                                         enough room and it did not fit the resort town’s
  so-called “veterans’ specials.” These cemeteries
                                                         image. In New York’s Westchester County, cemetery
  sometimes offer a free plot for the veteran, but
                                                         space is disappearing. Rubenstein writes, “Many of
  charge exorbitant rates for an adjoining plot for
  the spouse, as well as high fees for opening and       the county’s smaller cemeteries, both nonsectarian
  closing each grave. Evaluate the bottom-line cost      and those affiliated with a church or synagogue,
  to be sure the special is as special as you may be     are running out of space for in-ground burials. And
  led to believe.                                        although it is theoretically possible to create new
                                                         cemeteries in Westchester, it is unlikely that they
Cemeteries in Canada have shown trends similar           will be built because of the scarcity and high cost of
to those in the United States. Waugh writes, “Eth-       undeveloped land.”
nic and sectarian cemeteries are common in Canada           Interment.net is a database that allows the
and have restrictions based on memberships. Ceme-        browsing of 3,378,074 cemetery records across
teries may impose time limits on the use of plots or     7,144 cemeteries from around the world.
may reuse a plot for a relative after a specified
period of time. The trend away from ostentatious         Rubenstein, Carin. “Eternal Squeeze.” The New York Times,
monuments continues, sometimes at cemetery                 August 4, 2002.
insistence, but also because of high prices for mar-     Waugh, Earle. “Funeral Practices.” The 1998 Canadian Ency-
ble. Some memorial parks with special theme areas          clopedia. Historical Foundation of Canada. Available
or ethnic gardens have been established across the         online. URL: http://www.thecanadianencyclopedia.com/
country, and costs for their plots include a percent-      index.cfm?PgNm=TCE&TCE_Version=A&SectionId=
age for perpetual care.”                                   638711&MenuClosed=0. Posted September 6, 1997.
   In Mexico City, overcrowding is a major ceme-         Weissert, Will. “In Crowded Mexico City’s Cemeteries,
tery issue. Bodies interred at any of the city’s 103       Even Eternity Isn’t Always Permanent.” Associated Press
public cemeteries after 1975 must be exhumed after         Worldstream, May 28, 2002.
a minimum of seven years, to make room for
another body. Weissert writes, “An estimated 1.4
million people occupy such temporary graves in           charitable gifting      Many people with charitable
Mexico City. Things are so cramped that a market         intentions want to share their good fortune and
has sprung up in which families willing to evict their   leave a legacy upon their death. Charitable gifting is
loved ones can get thousands of dollars for the          a strategy that’s often suggested by estate and finan-
space.” Bodies buried before 1975 are allowed to         cial planners. Perhaps the most significant advan-
rest permanently. In some cases, families who own        tage is that federal estate taxes and probate costs will
a pre-1975 plot are cramming recently departed           be reduced because the gifted property is no longer
bodies into the same space. “Gravediggers exhume         part of one’s estate. Charitable gifting may also
remains and let relatives choose either to cremate       reduce state inheritance taxes. Those people with
them or put what’s left of the corpse in a small box     the largest estates are often encouraged to adopt a
which is attached to the top of the new coffin.”          pattern of charitable gifting for these reasons alone.
                                                                                         childhood grief 65

   Among the choices and decisions one has to           • poisoning; and
make when considering a charitable gifting strategy,    • falls.
are what to give and how to give. You would need
to consult with a financial adviser, who would likely    Injury rates vary with a child’s age, gender, race, and
ask some of the following questions: Should you         socioeconomic status. Younger children, male,
give cash, appreciated securities, or retirement        minorities, and poor children suffer disproportion-
assets? Should you make the gift outright, in trust,    ately. The majority of unintentional injury-related
during life, or after death? Should you consider        child deaths occur in the evening hours when chil-
establishing your own private foundation?               dren are likely to be out of school and unsupervised.
                                                            Among American children ages one to four,
                                                        unintentional injuries were the leading cause of
Cheyne-Stokes respiration      Abnormal respiration     death, followed by birth defects and cancer. From
in which periods of weak, shallow, slow breathing       ages five to 14, unintentional injuries, cancer, and
alternate with cycles of deep, rapid breathing. The     homicide were the leading causes of death. Between
condition is named after Scottish physician John        1980 and 1997 the death rate declined by almost
Cheyne (1777–1836) and Irish physician William          half for children ages one to four. Declines in deaths
Stokes (1804–78), who both practiced in Dublin          from unintentional injury and cancer were the
and wrote about the breathing pattern. Typically,       main causes of the overall drop in mortality.
over a period of one minute, a 10- to 20-second             The child death rate for African-American chil-
episode of apnea (temporary cessation of breath-        dren ages one to four remains almost twice that for
ing) or hypopnea (slow and shallow breathing) will      white children in the same age group (59.2 per
occur, followed by increasingly deeper and faster       100,000 vs. 31.5 per 100,000), according to 1997
breathing. The cycle then repeats itself. Each cycle    statistics. In 2000 the U.S. death rate for children
may last from 45 seconds to several minutes.            between ages one and 14 was 27 per 100,000.
Cheyne-Stokes respirations occur in congestive              Of the 10.8 million child deaths worldwide each
heart failure (CHF), more commonly in older             year, about 90 percent—9.7 million—occur in 42
patients with CHF, and may also be observed in          countries. Six nations account for half of the deaths—
patients suffering from diseases such as obesity that   India, Nigeria, China, Pakistan, Democratic Republic
retard circulation or in patients who have taken        of Congo, and Ethiopia. According to the World
drug overdoses, often occurring during sleep. They      Health Organization, more than 10 percent of those
are seen especially in comatose patients. Cheyne-       deaths could be prevented if women in poor coun-
Stokes breathing is also one of the signs of impend-    tries fed their infants breast milk and nothing else for
ing death. It is associated with depression of the      six months. Another 7 percent of those deaths could
respiratory center in the brain.                        be prevented if children in malaria-prone regions
                                                        slept under insecticide-treated mosquito nets.

child death    In general, children are primarily at
risk of unintentional injury-related death from:        childhood grief     In the United States, 5 percent of
                                                        children by age 16 years experience the death of a
• motor vehicle injuries, which include children as     parent; countless others lose siblings, grandparents,
  occupants, pedestrians, and bicyclists;               or close friends. In the past, children were thought
                                                        to be miniature adults and were expected to behave
• drowning;                                             as adults. But when a family member dies, children
• fire and burns;                                        react differently from adults in the family. The
• suffocation;                                          American Academy of Child and Adolescent Psy-
                                                        chiatry (AACAP) explains that “Preschool children
• choking;                                              usually see death as temporary and reversible, a
• unintentional firearm injuries;                        belief reinforced by cartoon characters who ‘die’
66 childhood grief

and ‘come to life’ again. Children between five and                 go, someone should be with the child to provide
nine begin to think more like adults about death,                  emotional support and to leave with the child if nec-
yet they still believe it will never happen to them or             essary. If possible, this should be a close friend or
anyone they know.”                                                 family member who does not need to attend the
   In clinical studies, according to Syuber and                    funeral and can be fully available to the child.
Mesrkhani, the most commonly encountered issues
include fear of being abandoned, fear that other                Unlike adults, bereaved children do not experience
loved ones or themselves might die, guilt over                  continual and intense emotional and behavioral
actual or imagined misbehavior, and difficulty in                grief reactions. Children may seem to show grief
school or in bonding with new caretakers.                       only occasionally and briefly, but in reality a child’s
   AACAP warns that when a sibling or parent dies,              grief usually lasts longer than that of an adult, most
the child’s shock and confusion is compounded if                likely because a child’s ability to experience intense
other family members, who may be so shaken by                   emotions is limited. Mourning in children may need
grief that they are not able to cope with the normal            to be addressed again and again as the child gets
responsibility of child care, are not available to the          older. Because bereavement is a process that con-
child, or at least appear to the child to no longer be          tinues over time, children will think about the loss
interested in him or her. They suggest:                         repeatedly, especially during important times in
                                                                their life, such as going to camp, graduating from
   Parents should be aware of normal childhood                  school, getting married, or giving birth to their own
   responses to a death in the family, as well as signs         children.
   when a child is having difficulty coping with grief.             Children at different stages of development have
   According to child and adolescent psychiatrists, it is       different understandings of death and the events
   normal during the weeks following the death for              near death, and the National Cancer Institute (NCI)
   some children to feel immediate grief or persist in          outlines the following Children’s Grief and Develop-
   the belief that the family member is still alive. How-       mental Stages:
   ever, long-term denial of the death or avoidance of
   grief can be emotionally unhealthy and can later                Infants
   lead to more severe problems.                                   Infants do not recognize death, but feelings of loss
                                                                   and separation are part of developing an awareness
The funeral itself may be frightening, especially to a             of death. Children who have been separated from
young child. When this is the case, the child should               their mother may be sluggish, quiet, unresponsive
not be forced to attend. In its place, AACAP suggests              to a smile or a coo, undergo physical changes (for
helping the child honor or remember the person in                  example, weight loss), be less active, and sleep less.
some other way, “such as lighting a candle, saying
a prayer, making a scrapbook, reviewing photo-                     Age two to three years
graphs, or telling a story.”                                       Children at this age often confuse death with sleep
   On the other hand, a young child who wants to                   and may experience anxiety as early as age three.
attend the funeral should not be forbidden. Syuber                 They may stop talking and appear to feel overall
and Mesrkhani write:                                               distress.

   Excluding children from family grief rituals such as            Age three to six years
   a funeral can be devastating, leading to a sense of             At this age children see death as a kind of sleep; the
   isolation or even guilt. Children know that an                  person is alive, but only in a limited way. The child
   important event is happening that they are inexpli-             cannot fully separate death from life. Children may
   cably forbidden to attend. On the other hand, forc-             think that the person is still living, even though he
   ing children to sit in a room with hysterical adults or         or she might have been buried, and ask questions
   to kiss a dead body can leave lasting traumatic mem-            about the deceased (for example, how does the
   ories. It is best to let children participate in the deci-      deceased eat, go to the toilet, breathe, or play?).
   sion whether they should attend the funeral. If they            Young children know that death occurs physically,
                                                                                             childhood grief 67

  but think it is temporary, reversible, and not final.       Is it going to happen to me?
  The child’s concept of death may involve magical           The death of another child may be especially hard
  thinking. For example, the child may think that his        for a child. If the child thinks that the death may
  or her thoughts can cause another person to                have been prevented (by either a parent or a doctor)
  become sick or die. Grieving children under five            the child may think that he or she could also die.
  may have trouble eating, sleeping, and controlling
  bladder and bowel functions.                               Who is going to take care of me?
                                                             Since children depend on parents and other adults
  Age six to nine years                                      to take care of them, a grieving child may wonder
  Children at this age are commonly very curious             who will care for him or her after the death of an
  about death, and may ask questions about what              important person.
  happens to one’s body when it dies. Death is
  thought of as a person or spirit separate from the      Leavitt cautions that changes in a child’s behavior
  person who was alive, such as a skeleton, ghost,        may be signs of anxiety, and that a pediatrician
  angel of death, or “bogeyman.” They may see death       needs to be contacted if problems such as these per-
  as final and frightening but as something that hap-      sist for more than a month:
  pens mostly to old people (and not to themselves).
  Grieving children can become afraid of school, have        Preschoolers bedwetting, thumb-sucking, or
  learning problems, develop antisocial or aggressive        increased clinginess.
  behaviors, become overly concerned about their             School-aged children sleep disturbances, night-
  own health (for example, developing symptoms of            mares, poor concentration, aches and pains.
  imaginary illness), or withdraw from others. Or,
                                                             Teenagers expressions of anger or sadness,
  children this age can become too attached and
                                                             problems with eating and sleeping, loss of inter-
  clinging. Boys usually become more aggressive and
                                                             est in activities, new difficulties at school.
  destructive (for example, acting out in school),
  instead of openly showing their sadness. When a
                                                          Any discussion with children about death should
  parent dies children may feel abandoned by both
                                                          include the proper words, such as “cancer,” “died,”
  their deceased parent and their surviving parent
                                                          and “death.” Substitute words or phrases (for exam-
  because the surviving parent is grieving and is
                                                          ple, “passed away,” “he is sleeping,” or “we lost
  unable to emotionally support the child.
                                                          him”) should never be used because they can con-
                                                          fuse children and lead to misunderstandings.
  Ages nine and older
  By the time a child is nine years old, death is known
                                                          American Academy of Child and Adolescent Psychiatry.
  to be unavoidable and is not seen as a punishment.          “Children and Grief.” American Academy of Child and
  By the time a child is 12 years old, death is seen as       Adolescent Psychiatry. Available online. URL: http://
  final and something that happens to everyone.                www.aacap.org/publications/factsfam/grief.htm.
                                                              Updated November 1998.
The NCI also advises that grieving children generally     Leavitt, Lewis. When Terrible Things Happen: A Parent’s
deal with three main issues:                                  Guide to Talking with Their Children. Johnson & Johnson
                                                              Pediatric Institute. Available online, URL: http://www.
  Did I cause the death to happen?                            jjpi.com. Posted November 7, 2002.
  Children often think that they have magical pow-        National Cancer Institute. “Loss, Grief, and Bereavement.”
  ers. If a mother says in irritation, “You’ll be the         Available online. URL: http://www.nci.nih.gov/
  death of me” and later dies, her child may wonder           cancerinfo/pdq/supportivecare/bereavement/patient/.
  if he or she actually caused the mother’s death.            Updated July 9, 2003.
  Also, when children argue, one may say (or think),      Shriver, Maria. What’s Heaven? New York: Scholastic, 1999.
  “I wish you were dead.” Should that child die, the      Silverman, Phyllis Rolfe. Never Too Young to Know: Death in
  surviving child may think that his or her thoughts          Children’s Lives. New York: Oxford University Press;
  actually caused the death.                                  2000.
68 children’s questions and curiosity

Syuber, Margaret L., and Violet Hovsepian Mesrkhani.          mation can be absorbed at a time. The child may
  “‘What Do We Tell the Children?’ Understanding              listen seriously to your answers and skip happily
  Childhood Grief.” Western Journal of Medicine 174, no. 3:   away saying, “Well, I’m never going to die.” The
  187–191.                                                    NIMH cautions that you should not feel compelled
Wolfelt, Alan D. “Helping Children with Funerals.” The        to contradict the child or think that your efforts
  Funeral Directory. Available online. URL: http://           have been wasted. You have made it easier for the
  www.thefuneraldirectory.com/helpchild.html. Down-           child to come back again when more answers are
  loaded June 5, 2003.                                        needed.
                                                                  David Kessler, writing in The Needs of the Dying
                                                              (HarperCollins), says it is always best to answer chil-
children’s questions and curiosity Children gen-              dren’s questions and explain about death before
erally are far more comfortable talking about death           someone they love is dying and the situation
and dying than are adults. According to Partner-              becomes emotionally charged. “You can teach your
ship for Children, an organization aimed at improv-           child about funerals and rituals when a fish in the
ing the emotional well-being of children and young            aquarium dies.” He says to help the child bury the
people, “Children begin to develop great curiosity            fish in the backyard. “Show him how it’s done; let
about death as soon as they begin to experience               him see that we continue to respect bodies even
make-believe deaths in fairy tales, games and tele-           after the soul has flown. If you send the child away,
vision shows. Children pretend to be dead in games,           then quickly flush the fish down the toilet, you are
they kill ‘bad guys’ in video games and often discuss         teaching the child that beloved things simply disap-
death freely with other children. Children usually            pear. But if you use the fish’s passing as an opportu-
talk as easily about death and dying as they discuss          nity to discuss death, to place it in perspective and
sports, favorite toys or foods they like. When some-          give the child an opportunity to grieve, you teach
one they love dies, they are saddened by the death            him how to grieve and to understand that death is
but may still have a lot of curiosity about the dead          always a part of life.”
person and talk openly about their feelings. How-
ever, when children sense that an adult is uneasy             Boritzer, Etan. What Is Death? Santa Monica, Calif.: Veron-
discussing death, they may become uneasy about                   ica Lane Books, 2000.
the discussion themselves.”                                   National Institutes of Health. “Caring about Kids: Talking
   In their booklet, “Caring About Kids: Talking to              to Children about Death.” Available online. URL:
Children about Death,” the National Institute of                 http://www.cc.nih.gov/ccc/patient_education/pepubs/
Mental Health (NIMH) explains that young chil-                   childeath.pdf. Posted 1995.
dren’s natural curiosity about dead insects, flowers,          Partnership for Children. “Talking to Children about Death.”
and animals provides excellent opportunities to                  Availableonline.URL: http://www.partnershipforchildren.
relate their questions to people’s deaths. Children              org.uk/resources/discussing_death.html. Downloaded
may wish to examine the dead insects or animals                  June 5, 2003.
closely, or they may ask detailed questions about
what happens physically to dead things.
   Although this interest may seem repulsive or               choosing to stop eating and drinking         Occasion-
morbid to adults, it is a way of learning about               ally a terminal patient will make a deliberate choice
death. Children should not be made to feel guilty or          to stop taking in food and fluids. Lynn and Harrold
embarrassed about their curiosity. Their interest             explain that the patient may actually say he or she
provides an opportunity to explain that all living            is doing this in order to speed up the dying process.
things die and make room for new living things.               “These are people in the last stages of a terminal dis-
This kind of answer may satisfy for the moment, or            ease. They do not suffer from a mental illness or
it may lead to questions about our own mortality.             other condition that has affected their reasoning.
Honest, calm, and simple answers are called for.              They are not suicidal in the usual sense of the word.
When talking to a very young child, it is important           They have concluded that the burden of living has
to keep in mind that only limited amounts of infor-           gotten so great that they would rather die sooner.”
                                                                                     classification of deaths 69

   The Compassion in Dying Federation lists it as              http://www.compassionindying.org/gentle_death.php.
one of the individual choices that can play a major            Downloaded June 5, 2003.
role at the end of life:                                    Lynn, Joanne, and Joan Harrold. Handbook for Mortals:
                                                               Guidance for People Facing Serious Illness. New York:
   Another option available to people who are alert and        Oxford University Press, 1999.
   able to make decisions is simply to stop eating and
   drinking. This also reportedly causes a peaceful
   and gentle death, though it takes a number of days       Christianity and death The name Christian covers
   and a strong determination. Again, this is your          a broad variety of cultures across all continents, and
   right, and the physician should provide sedation         more than 200 different Christian denominations.
   and pain medication to ensure comfort. Providing         Christian funeral rituals may differ among denom-
   this symptom relief is generally considered ethical      inations, and even from church to church within a
   and legal because the sedation is given to relieve       denomination.
   suffering, not cause death.                                 Christianity believes that life is a preparation for
       Stopping eating and drinking is viewed as a vari-    death, and that resurrection brings eternal life to the
   ant of stopping other forms of life-sustaining treat-    soul. Christians believe that the soul leaves the body
   ment. It is therefore theoretically available to those   after death, and that if the deceased followed the
   who are not imminently dying. The process                teachings of Jesus Christ, doing good things while
   requires substantial self-discipline and usually takes   alive, his or her soul will go to heaven. This issue of
   one to three weeks, so there is an opportunity for       judgment has two meanings to Christians. First,
   a change of mind. There also is time for the family      each person is judged after death according to his or
   to come together and make the kind of psycholog-         her deeds on Earth. Second, all of mankind will be
   ical and emotional transition that is necessary for      judged together on the Day of Judgment or Second
   grief and adjustment to the loss of their loved one.     Coming, when Christ will again appear, this time to
                                                            take the righteous into Heaven.
The choice to cease nourishment intake may be dis-             At a typical Christian funeral, prayers, hymns, and
turbing to family members and the medical person-           eulogies are offered to remember and praise the per-
nel. Lynn and Harrold caution, “When a patient              son who has died. Many churches have specially
does make such a choice, the family and caregivers          written funeral services, as well as special readings,
do need to be sure that the patient is not suffering        prayers, and hymns. Catholic churches hold a funeral
from depression or inadequate pain control. Per-            Mass. After the service is performed in a church, the
haps these conditions could be adequately managed           body is transported to a cemetery in a hearse, where
and once under control the patient may no longer            a final, brief ceremony is held to remember the dead.
want to hasten death. It is very important to con-             The first Christians were buried outside a city,
sider the conditions that the patient feels are too         often in CATACOMBS. In time, the wealthy sought
great a burden and see if they can be relieved. These       burial inside a church, usually under the floor, or in
burdens may be emotional issues such as discord in          a crypt, preferably close to the altar. As interior
the family or spiritual issues.                             space became scarce, churchyards were created.
    “After the emotional, spiritual and symptom                Christianity encourages the generosity of organ
management issues have been adequately                      and body donation.
addressed, the patient may still choose to refuse to           See also CATHOLICISM AND DEATH; CEMETERIES;
eat. If this happens, it usually is in the very last days   PROTESTANTISM AND DEATH.
of the course of the disease. Just as a patient can
refuse surgery or chemotherapy that might prolong
life, a patient also can refuse to eat. However,            classification of deaths The system for classifying
finally, the patient’s decision binds everyone else.”        cause of death, called the International Classifica-
                                                            tion of Diseases (ICD), is revised occasionally to
Compassion in Dying Federation. “A Gentle Death: Free-      reflect changes in medical practices and new med-
  dom to Choose at Life’s End.” Available online. URL:      ical knowledge. As each ICD revision results in a
70 clinical death

degree of discontinuity in cause-of-death statistics,           when the patient is “declared” dead). A person is
a ratio of comparability is used to adjust for classifi-         clinically dead if he is in cardiac arrest and his pupils
cation changes in the revisions.                                do not contract when light is shone into them. Sher-
   The history of the International Classification of            win B. Nuland describes clinical death in How We
Diseases extends back to the late 19th century,                 Die: Reflections on Life’s Final Chapter (Vintage Books):
when the need for standardizing classification con-              “Clinical death is the term used to encompass that
cepts and terminology was recognized by the med-                short interval after the heart has finally stopped,
ical community in Europe. Since 1900 the ICD for                during which there is no circulation, no breathing,
mortality has been modified about once every 10                  and no evidence of brain function, but when rescue
years, except for the 20-year interval between the              is possible.” If this stoppage occurs suddenly, as in
ICD-9 and ICD-10.                                               cardiac arrest or massive hemorrhage, a brief time
   Classification of the deaths and injuries that               remains before vital cells lose their viability, during
occurred as a result of the events of September 11,             which measures such as cardiopulmonary resuscita-
2001, presented CDC’s National Center for Health                tion (CPR) or rapid transfusion may succeed in
Statistics (NCHS) with a dilemma. Under the then                resuscitating a person whose life has seemingly
current classification systems for mortality and mor-            ended; the time is probably no more than four min-
bidity, the World Health Organization’s International           utes. These are the dramatic moments we read about
Classification of Diseases, Tenth Revision (ICD-10),             and see portrayed on our television screens.
and the United States’ International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-
9-CM), deaths and injuries associated with acts of              closure    When used by family and friends follow-
terrorism could not be identified uniquely.                      ing death of a loved one, it refers to the finalization
   For the new terrorism codes to be used for the               or wrapping up of everything that can be done for
classification of deaths and injuries, the incident in           the deceased so they can feel free to move onward
question must be designated as a terrorist act by the           with their own lives. In normal deaths, the funeral
U.S. Federal Bureau of Investigation (FBI), which               itself may provide closure. In violent deaths, such as
has jurisdiction over the investigation and tracking            by murder or terrorism, closure may not occur until
of terrorism in the United States.                              those responsible for the death are apprehended,
   Information on causes of death is recorded on                tried, and sentenced.
death certificates by physicians, medical examiners,
and coroners, and reported to state vital statistics
offices. Demographic information is provided by                 coffin A box or chest for burying remains; also
funeral directors, based on information from                    called a CASKET. Coffin is the generic term in English,
informants, who are usually family members. How                 but casket has been used in America since the mid-
deaths are classified is very important because the              1800s—the reason for this usually being credited to
compiled statistics are used to determine where                 the funeral industry’s attempt to “prettify” death by
research time and funding is spent, and where                   giving the coffin a name that at the time was used
changes in the law may need to be considered.                   for containers holding jewels or other valuables. To
                                                                some people, there is a difference between the two,
Anderson, R. N., and H. M. Rosenberg. “Disease Classifi-         with coffin meaning a hexagonal container with a
  cation: Measuring the Effect of the Tenth Revision of         specific shape—widest at the shoulders and nar-
  the International Classification of Diseases on Cause-         rower at the head and feet. Caskets, on the other
  of-death Data in the United States.” Statistics in Medicine   hand, are rectangular, with straight sides and ends.
  22, no. 9 (May 15, 2003): 1551–1570.                          The coffin shape is ancient and can still be seen as
                                                                the predominant style in many European countries.
                                                                   According to Delaware Department of Trans-
clinical death Cessation of heartbeat and breath-               portation archaeologists, who excavated a colonial
ing, or when spontaneous circulation and respiration            burial site, hexagonal coffins were used in America
ceases (the date and time on the death certificate               until the mid- to late 19th century. “During the
                                                                                                          coma 71

Colonial period, coffin building in rural areas was           undertakers prior to the late 1800s to gently hold
done by a local carpenter, cabinetmaker, or wheel-           the deceased’s eyelids closed until the muscles and
wright. Before beginning work, the carpenter                 tissues set in a fixed position. “Sometimes, the coins
needed only a few measurements from the corpse.              were left in place even though they were no longer
Generally, two measurements were sufficient—the               needed. Without knowing the exact reason for
length from head to foot, and the width at the               using the coins, people explained their presence in
shoulders or elbows. The coffin itself was built of six       another way. Harkening back to the ancient [Greek
pieces—bottom, head, foot, two sides, and top or lid,        and Roman] mythology, it was believed that the
and the only tools required were a few saws, planes,         deceased needed money in the afterlife, especially to
a hammer, and various marking tools.”                        pay Charon who operated the ferry across the River
                                                             Styx, which separated the earthly world from the
Delaware Department of Transportation. “Archaeology—         underworld. Other cultures also share the belief
   An 18th-Century Family Cemetery, Sussex County,           that the dead may have to provide a payment so
   Delaware.” Available online, URL: http://www.deldot.      they are thus prepared.”
   net/static/projects/archaeology/cemetery/cemetery.html.
   Downloaded June 13, 2003.
                                                             columbarium A structure, sometimes a VAULT, with
                                                             niches (small spaces or compartments) for holding
coffin birth A term used by coroners for a spon-              urns or other approved vessels containing cremated
taneous birth by a dead pregnant woman. It occurs            remains. It may be outdoors or indoors as part of a
when the gas that builds up naturally in the                 mausoleum or chapel. In many instances, a colum-
abdomen and pelvic area of a decomposing body                barium is found underneath a cathedral. Consumers’
produces enough pressure to propel the unborn                Research Magazine cautions that “placement in a
child through the birth canal and out of the corpse.         columbarium adds to the costs” of a funeral.
The term no longer receives much usage; it was
coined before bodies were embalmed. If a body is
properly embalmed, it’s not likely to happen; for            coma A state of unresponsive unconsciousness,
this reason, coffin birth is no longer described in           with total unawareness of self and surroundings. A
medical books. The term became part of the daily             person in a coma cannot be aroused even by pow-
news following the disappearance of the pregnant             erful stimulation, and does not respond to external
Laci Peterson in California on Christmas Eve, 2002,          stimuli (such as a pinprick or a shout) or to inner
when several months later her torso washed ashore            needs (such as a full bladder). Turkington writes, “A
in San Francisco Bay separately from the body of             patient may remain deeply comatose but alive for
her unborn son, which was much less decomposed.              many years if the brain stem is still functioning.
Experts suggested that a coffin birth may have               Once brain damage spreads to the lower brain stem
taken place. When a pregnant woman dies and her              laryngeal function (coughing and swallowing),
body is not embalmed, it can take weeks or even              breathing will begin to deteriorate. Coma may occur
months for a postmortem birth to take place; the             in various degrees of severity. In mild forms, the
Peterson baby appeared to have been “born” in                patient may respond to stimuli by speaking a few
April 2003. ABC News quoted experts as saying, “If           words or moving a body part. In more severe cases,
someone is pregnant and decomposing in a temper-             the patient cannot respond in any way. But even
ature of 110 degrees, it will happen much more               deeply comatose patients may continue to breathe,
quickly than if they’re decomposing in a tempera-            cough, yawn, blink, or exhibit eye movements.
ture of 40 degrees.”                                         These automatic responses indicate that the lower
                                                             brainstem, which controls these responses, is still
                                                             functioning.”
coins placed on the eyes of the dead According
to the Museum of Funeral Customs, Springfield,               Turkington, Carol. “Coma,” in The Brain Encyclopedia. New
Illinois, this custom arose from the use of coins by            York: Facts On File, 1996.
72 comfort care

comfort care      Distinguished from care with the          for “channeling”—part of the fast-growing “New
goal of curing, comfort care seeks primarily to make        Age” movement, a modern-day mysticism that
a patient comfortable even when no cure is possible.        draws from Buddhism, Hinduism, and Western
Comfort care emphasizes good pain management,               occultism, among other traditions.
patient’s wishes, and adequate spiritual and psy-              Classic channeling—sometimes called trance
chological support at the end of life. Examples of          channeling—is a paranormal experience alleged to
comfort care: medication to relieve pain or fever,          be contact between a human being and an entity
oxygen to make breathing easier, keeping the                from the spirit world. Information is communicated
patient clean and dry, turning the patient over,            to or through a human being from another level of
keeping a person’s lips or mouth moist. In their            consciousness. A spirit enters the mind of the chan-
study, Tschann et al. concluded that family involve-        nel, who becomes its “mouthpiece.” The spirit then
ment before death may reduce the use of technol-            offers advice and counsel on everything from med-
ogy and increase the use of comfort care as patients        ical problems to financial investments to improving
die. Sometimes the term “comfort care” is used              one’s love life. Over the centuries, channels have
interchangeably with “palliative care”; some people         been called by a variety of names: shamans, medi-
use “comfort care” only for people near death.              cine men, witch doctors, masters, mystics, medi-
   See also PALLIATIVE CARE; PALLIATIVE CARE FOR            ums, and oracles.
CHILDREN.                                                      The famous stage magician Harry Houdini spent
                                                            30 years investigating alleged examples of commu-
Tschann, J. M., S. R. Kaufman, and G. P. Micco. “Family     nication with the spirit world. He said he had not
   Involvement in End-of-Life Hospital Care.” Journal of    “found one incident that savored of the genuine.” He
   the American Geriatrics Society 51, no. 6 (June 2003):   claimed he could duplicate any effect produced in a
   835–840.                                                 seance by purely physical means, and he exposed
                                                            some extremely clever frauds and skillful illusions.
                                                            Concealed microphones, wires, mirrors, projectors,
communication with the dead Followers of mod-               ventriloquism, sleight of hand, and other ingenious
ern Spiritualism believe that communication with            techniques were used to deceive the gullible.
the so-called dead in the spirit world is both possi-          But there are serious mediums—or channelers,
ble and necessary to learn God’s natural laws.              as they are called today—who have stood up under
According to Heinen, “Spiritualism often describes          the most rigorous scrutiny of investigators. Despite
itself as a science, a philosophy, and a religion based     meticulous testing, they have given no evidence of
on the continuity of life as proved through medi-           any type of fraud.
umship. It also has been a lightning rod for skeptics          The inventor Thomas Edison conceived the pos-
and debunkers who are critical of the beliefs them-         sibility of instrumental communication with the
selves, or of unscrupulous practitioners faking             dead. But experimenters had to admit failure in
sounds and apparitions during séances to take               establishing an electronic link with the spirit
advantage of vulnerable, grieving people.”                  world—until the late 1950s. In 1959 the Swedish
    Interest in the possibility of communicating with       filmmaker and painter Friedrich Jurgenson played
the dead is escalating. The National Science Foun-          back tapes of birdcalls he had recorded in a Swedish
dation found in its “Indicators 2002” survey that in        forest. To his astonishment, he heard what he
1990 18 percent of Americans believed people could          believed to be his dead mother’s voice on the tape.
telepathically reach out to the deceased. The figure         This began a series of experiments to record spirit
in its most recent survey stands at 28 percent. Vir-        voices. Hundreds of voices have been heard on
tually all civilizations have had some form of belief       his tapes.
in an afterlife. According to the Worldwide Church             Other researchers claim to have recorded the spirit
of God, the idea that the spirits of people who have        voices of Churchill, Hitler, Stalin, Tolstoy, and many
“passed over” can make contact with the living is           other famous men and women of history. The voices
popular today mainly because of the modern craze            usually require extreme amplification, and often the
                                                                                complicated grief reaction 73

language patterns are disjointed and confused. Yet          Compassion in Dying Federation               Provides
something is unquestionably coming across.                  national leadership for client service, legal advo-
   Channeling, mediumship, and spiritism are often          cacy, and public education to improve pain and
nothing more than a fraud perpetrated on gullible           symptom management, increase patient empower-
people. Sometimes it is the channel who is gullible.        ment and self-determination, and expand end-of-
In some cases, sincere channels may believe they            life choices to include aid-in-dying for terminally ill,
are being used by separate, otherworldly entities,          mentally competent adults. Contact information:
but in actuality are not. Psychic researchers believe
                                                            Compassion in Dying Federation
that channeling is often a self-generated experience.
The channels are simply “going within.” It is their         6312 SW Capitol Highway
own inner subconscious speaking, not some out-              Suite 415
side entity. Sometimes it is not a matter of conscious      Portland, OR 97239
fraud.                                                      (503) 221–9556
                                                            (503) 228–9160 (fax)
                                                            info@compassionindying.org
Heinen, Tom. “More Taking Interest in Spiritualism.” Mil-
                                                            http://www.compassionindying.org
   waukee (Wisconsin) Journal Sentinel, September 28,
   2002.
Worldwide Church of God. “Communication with the
   Dead: Is It Possible?” Available online. URL: http://    competency       A legal term referring to a person’s
   www.wcg.org/lit/booklets/spirit/spirit4.htm. Down-       ability or lack thereof to comprehend. When a per-
   loaded June 13, 2003.                                    son is judged “competent,” it indicates that he or
                                                            she has the mental status to manage his or her own
                                                            affairs. The term competence is used to refer to the
                                                            legal standing of such a person. Only a court can find
Compassionate Friends, Inc., The (TCF) A national
                                                            an individual to be incompetent and assign that per-
nonprofit, self-help support organization that offers
                                                            son a guardian to manage his or her affairs. If a per-
friendship and understanding to bereaved parents,
                                                            son is declared legally incompetent, the right to
grandparents, and siblings. There is no religious affil-
                                                            make decisions is lost. A physician who finds that a
iation and there are no membership dues or fees.
                                                            patient is mentally incapacitated to make his or her
The mission of the Compassionate Friends is to assist
                                                            own decisions, however, is not required to have a
families toward the positive resolution of grief fol-
                                                            court declare the patient incompetent in order to
lowing the death of a child of any age and to provide
                                                            consult the patient’s living will or authorized deci-
information to help others be supportive. The Web
                                                            sion-maker for medical decisions. The New Jersey
site holds regular live chats for those dealing with
                                                            Comfort Care Coalition cautions that “some legally
general bereavement issues, pregnancy loss and
                                                            incompetent people have the capacity to understand
infant death, men’s chat, siblings, no surviving chil-
                                                            some things, and their feelings and opinions should
dren, bereaved one year or less. Members of three or
                                                            be respected during any decision-making process.”
more families who are grieving the death of a child
                                                            Competence and capacity or incompetence and inca-
(grandparents, siblings, or other family members)
                                                            pacity are often used interchangeably, so it is impor-
may apply to establish a TCF chapter in their com-
                                                            tant to determine which someone means.
munity. Contact information:
                                                               See also CAPACITY.
The Compassionate Friends, Inc.
P.O. Box 3696
Oak Brook, IL 60522–3696                                    complicated grief reaction   Prolonged grief lasting
(630) 990–0010 or (877) 969–0010 (toll free)                longer than 12 months, with specific symptoms of
(630) 990–0246 (fax)                                        psychological trauma and depression. The psycho-
nationaloffice@compassionatefriends.org                      logical trauma symptoms include: intrusive images
http://www.compassionatefriends.org                         or thoughts, especially about the deceased person;
74 condolence letters

severe emotional reactions (e.g., numbness, crying,       purposelessness/feeling of futility, (2) sense of
startle reaction); depressive symptoms; neglect of        numbness or absence of emotional responsiveness,
adaptive strategies at work or home; poor personal        (3) disbelief about the death, (4) sense of life being
hygiene; low energy; feeling excessively alone and        meaningless, (5) feeling that part of oneself has
empty; diminished sense of self-esteem; guilt; exces-     died, (6) lost sense of trust or control, (7) assuming
sive avoidance of tasks reminiscent of the deceased       harmful behaviors of, or related to, the deceased, or
person; unusual sleep disturbances.                       (8) excessive irritability or anger about the death.
   Complicated grief reactions require more com-          These symptoms must last for at least six months
plex therapies than uncomplicated grief reactions.        and cause functional impairment to be classified
Adjustment disorders (especially depressed and            as a complicated grief reaction.” Huffman notes
anxious mood or disturbed emotions and behav-             that these criteria do not appear in the Diagnostic
ior), major depression, substance abuse, and even         and Statistical Manual of Mental Disorders, 4th ed.,
post-traumatic stress disorder are some of the com-       but, “according to expert opinion, represent a psy-
mon problems of complicated bereavement. Com-             chiatric disorder with distinctive symptoms and
plicated grief is identified by the extended length of     outcomes.”
time of the symptoms, the interference caused by
the symptoms, or by the intensity of the symptoms         Huffman, Grace Brooke. “Family Physicians Working with
(for example, intense suicidal thoughts or acts).            Bereaved Patients.” American Association of Family
   Complicated or unresolved grief may appear as a           Physicians. Available online. URL: http://www.aafp.org/
complete absence of grief and mourning, an ongo-             afp/20020301/tips/12.html. Posted March 1, 2002.
ing inability to experience normal grief reactions,       National Cancer Institute. “Loss, Grief, and Bereavement.”
delayed grief, conflicted grief, or chronic grief. Fac-       Available online. URL: http://www.nci.nih.gov/
tors that contribute to the chance that one may              cancerinfo/pdq/supportivecare/bereavement/patient.
experience complicated grief include the sudden-             Updated July 9, 2003.
ness of the death, the gender of the person in
mourning, and the relationship to the deceased (for
example, an intense, extremely close, or very con-        condolence letters At one time, people sent let-
tradictory relationship). Grief reactions that turn       ters of condolence to families who had lost loved
into major depression should be treated with both         ones; today, special “greeting” cards are more com-
drug and psychological therapy. One who avoids            monly sent, although a personal letter of condo-
any reminders of the person who died, who con-            lence may be considered more meaningful. The
stantly thinks or dreams about the person who died,       military and businesses are most likely to send con-
and who gets scared and panics easily at any              dolence letters today.
reminder of the person who died may be suffering             After studying thousands of condolence letters
from post-traumatic stress disorder. Substance abuse      and analyzing their structure, The Western Wash-
may occur, frequently in an attempt to avoid painful      ington University Counseling Center identified
feelings about the loss and consequent symptoms           seven key components:
(such as sleeplessness), and can also be treated with
drugs and psychological therapy.                          1. Acknowledge the loss.
   Huffman, explains that “a complicated grief            2. Express your sympathy.
reaction is characterized by at least three of the fol-   3. Note special qualities of the deceased.
lowing four symptoms on a daily basis or to a             4. Recount a memory about the deceased.
marked degree: (1) intrusive thoughts about the
deceased, (2) yearning for the deceased, (3) search-      5. Note special qualities of the bereaved.
ing for the deceased, or (4) excessive loneliness. If     6. Offer assistance.
the first criterion is met, the physician should find       7. Close with a thoughtful word or phrase.
out if the patient has four of the following eight
symptoms at least daily or to a marked degree: (1)        They also suggest three optional components:
                                                                           coping with the death of a child 75

1. Share your philosophy of life or provide a reli-          to the world after death. Life in Confucianism is to
   gious commentary.                                         fulfill one’s responsibility to society; if that is done,
2. Share your own grief experiences, but don’t               then the person will die “immortal.”
   compare them with those of the bereaved.
3. Include a quotation, reading, or historic letter.
                                                             coping with the death of a child A child’s death is
                                                             particularly tragic, with the grief period likely to be
Western Washington University Counseling Center. “Com-
                                                             especially intense and prolonged. As Goodman et al.
  posing Letters and Notes of Condolence.” Available
                                                             found in their study of the literature, losing a child
  online. URL: http://www.wwu.edu/chw/counseling/
                                                             “eclipses and diminishes” other losses. A young child’s
  specific_topics/st_grief/condolence.html. Downloaded
                                                             death is usually felt to be unfair. Common thoughts
  June 14, 2003.
                                                             that grieving parents must deal with include:

                                                             • Children aren’t supposed to die. It’s not natural.
Confucianism and death         Confucianism is not a
religion in the sense of man relating to the Almighty,       • My son (or daughter) never had an opportunity
but is rather an ethical system and philosophical              to experience a full life.
doctrine teaching man how to get along with his              • My child was innocent and didn’t deserve to die.
fellow man. A religion of optimistic humanism, its
founding goes back to one man, known as Confu-               The National Mental Health Association adds, “A
cius, who was born in China in 550 B.C.E. The teach-         child’s death arouses an overwhelming sense of
ings of Confucius emphasize love for humanity, with          injustice—for lost potential, unfulfilled dreams and
high value given to learning and to devotion to fam-         senseless suffering. Parents may feel responsible for
ily (including ancestors), peace, and justice.               the child’s death, no matter how irrational that may
    Confucianism holds the view that the “problem”           seem. Parents may also feel that they have lost a
of human life is more important than the “problem”           vital part of their own identity.”
of human death, and so speaks little of death. Added             The issue of coping with loss of a child differs
to that, according to Confucianism, is the fact that         according to the child’s age. As grief therapist Bar-
whether a person lives or dies is determined by the          bara J. Paul explains, “The younger the son or
decree of Heaven, and thus beyond our control.               daughter is, the more parents are involved in caring
Because death is fate, there is no point in worrying         for that child. Daily living and routine is affected
about it. Death is the time to rest; a release from the      and simple tasks can become overwhelmingly
labor of this world.                                         painful. Parents feel the enormous emptiness of the
    Along with that, Confucianism strongly believes          home and every aspect of life.
that both life and death should serve morality.                  “With an adolescent or young adult living at
Therefore, because our death should have a moral             home, parents are still involved with many aspects
significance, we should spend our life preparing for          of their child’s life and family routine. These parents
a moral death by giving our life to a moral cause.           feel strongly about the death occurring just as the
And if we live our life altruistically, we will not be       young person was beginning to live life. Their chil-
worried about death. Confucianism attempts to rise           dren have begun to develop lives separate from
above the negativity and destructiveness others feel         home, and parents often look for contact and con-
about death. Instead, it teaches that even though            nection with the son or daughter’s friends.”
the physical body will be gone, the person can attain            The death of a young child from disease exacer-
immortality through his or her lasting influence on           bates the coping challenge because of the additional
subsequent generations.                                      issues preceding the actual death. Because children’s
    Confucius teaches that until one understands             bodies do not break down in the same ways as
fully about life, one cannot understand death.               adults’, a terminally ill child may rally for months,
Because Confucianism places more emphasis on                 if not years. Painful memories of the child’s suffer-
responsibility in one’s lifetime, it pays little attention   ing may be as difficult to cope with as the death
76 coping with the death of a coworker

itself; and the fear, anxiety, and depression parents           Rosof, B. D. The Worst Loss: How Families Heal from the Death
have endured may have already strained family                      of a Child. New York: Henry Holt, 1995.
relationships.                                                  University of Iowa Health Science Relations. “Elderly
                                                                   Loss: Treat It with Respect.” Virtual Hospital. Avail-
                Loss of an Adult Child                             able online. URL: http://www.vh.org/adult/patient/
Parents who lose an adult child also face special                  internalmedicine/prose/elderlyloss.html. Revised
challenges. THE COMPASSIONATE FRIENDS (TCF)                        December 2003.
organization explains, “The grief and the healing
process contain the same elements for all bereaved
parents, but for those whose adult child has died               coping with the death of a coworker Because
there are additional factors which affect their grief.          people usually spend as much or more time with
Other people often assume that, because the ‘child’             their coworkers as they do with family or friends,
was an adult, the pain of losing them is less.”                 the death of a coworker can profoundly affect
   Although any bereaved parent can be racked                   employees and their ability to function in the work-
with the guilt of outliving a child, TCF notes that             place. The sense of sadness will be similar to that of
parents who lose adult children to “social problems”            losing a family member or close friend. Because
such as drug use or alcohol-induced accidents face              most working people are under age 65, the death of
the double guilt of “what could I have done better              a coworker likely will cause added feelings of
to have prevented this.” In coping with these losses,           unfairness and untimeliness. If they are of a similar
many parents have found it especially helpful to                age, coworkers may feel vulnerable, frightened, and
become involved in support groups dealing with                  depressed.
the issue involved. By helping others to either pre-               The Stanford Help Center offers the following
vent or deal with what they or their child have                 suggestions for coping with the death of a co-
experienced, they feel their child’s loss will at least         worker:
serve some purpose and be a bit more acceptable.
   Dealing with the death of an adult child is often               Be aware of each other. If it appears that some-
especially difficult among the elderly, who have par-               one is having a serious problem coping with the
ticular problems in coping. “The elderly are less likely           death, express concern and encourage them to
to cope as well as young people because of the added               seek professional assistance, and have a list of
years of meaning behind the loss, and the fewer years              resources available.
with which to move on,” according to Kathleen Buck-                Accept that work may be affected. You and your
walter, professor of nursing at the University of Iowa             co-workers’ job performances and interactions
College of Nursing, and a specialist in gerontology.               may be affected by the stress. In time, things will
                                                                   return to normal. If the death is suicide, homi-
The Compassionate Friends. “The Death of an Adult Child.”          cide, unexpected, or occurred in the workplace,
   Available online. URL: http://www.compassionate                 the emotional trauma experienced will be more
   friends.org/Brochures/adult_child.htm. Downloaded               severe and the need for outside help will be
   June 16, 2003.                                                  greater.
Goodman, M., et al. “Cultural Differences among Elderly
   Women in Coping with the Death of an Adult Child.”              Contact the family of the deceased. Consider
   Journal of Gerontology 46 no. 6 (1991): S321–S329.              sending cards, flowers, or other gifts, such as a
Mehren, E., and H. Kushner. After the Darkest Hour the Sun         book of memories written by the staff, to a sur-
   Will Shine Again: A Parent’s Guide to Coping with the Loss      viving spouse or child.
   of a Child. New York: Fireside, 1997.                           Attend or organize a memorial service. Whether
Paul, Barbara J. “Losing a Son or Daughter.” AARP Grief            conducted on or off the work site, a memorial
   & Loss Program. Available online. URL: http://www.aarp.         service can be another important step for
   org/griefandloss/articles/16_a.html. Downloaded June            acknowledging feelings and coming to terms
   16, 2003.                                                       with the death.
                                                                       coping with the death of a parent 77

   Consider establishing a memorial at work. Buy-         tion, especially if the parent is elderly, is usually that
   ing a bench or planting a tree are examples of         the person lived a long, full life or was released from
   ways to honor the deceased.                            pain and suffering. Such rationalization does not
                                                          make grief any easier to bear. According to Univer-
   See also WORKPLACE DEATHS.                             sity Hospital, Newark, New Jersey, the intensity and
                                                          length of the grieving process depends on a number
Stanford Help Center. “When a Coworker Dies.” Califor-    of factors, including the relationship with the parent,
   nia State University, Sacramento. Available online.    the individual’s age, religious beliefs, coping abili-
   URL: http://www.csus.edu/eapprogr/dies.pdf. Down-      ties, support systems, and how the loss is perceived
   loaded June 16, 2003.                                  as changing his or her life. However, there are com-
                                                          mon reactions to the death of a loved one.
                                                              During the first few hours following the death of
coping with the death of a friend        Losing a close   a parent, the adult child may experience denial, char-
friend may cause as long and intense a mourning           acterized by shock, disbelief, numbness, and anger.
period as losing a close family member. Jan Yager,        He or she may be angry at the doctors who could not
author of Friendshifts: The Power of Friendship and       save the parent, and may even feel angry at the par-
How It Shapes Our Lives (Hannacroix Creek Books,          ent for not taking better care of his or her health. This
1999), says, “A friend is a second self. With each        anger is commonly replaced by guilt and depression.
friend we share something special that no one else            An individual may believe that if she had just
has. When they die, it’s like losing a part of your-      done something she could have prevented the death,
self.” For this reason, it is important to allow your-    and minor disagreements that would not normally
self to go through the full grieving process. Yager       deserve a second thought can become painful mem-
offers the following suggestions:                         ories. Following guilt, depression sets in, which is the
                                                          beginning of acceptance, the final stage of grief.
• Memorialize your friend. Do something positive              As the initial shock of death fades and acceptance
  out of the tragedy with mutual friends.                 sets in, it is common for bereaved children to feel pan-
• Talk with others about your friend and the loss         icky and lost. When a parent dies, many adult children
  you feel.                                               eventually realize that they have not just lost a par-
• Keep in touch with your friend’s parents or other       ent, but also an adviser, role model, and friend.
  family members.                                         Throughout adulthood, it is not unusual for children
                                                          to seek their parent’s advice before making large pur-
• Be kind to yourself and recognize that this is a        chases or investments, or even to request counsel on
  major and powerful loss.                                everyday topics like child-rearing, relationships, and
• Join a bereavement support group.                       health. Without the parent, the adult child may sud-
• Do not underestimate the power of making new            denly feel very alone, which can result in feelings of
  friends.                                                panic, loss, and a possible reoccurrence of depression.
                                                              Grief counselors such as Saynor and those at
Burby, Liza N. “Coping with a Friend’s Death.” Newsday,   GriefLink offer the following suggestions for coping
  January 20, 1998.                                       with the death of a parent:

                                                          • Resist the temptation to dismiss your parent’s
coping with the death of a parent         Although          death as “timely” or “inevitable.” Although this is
everyone knows that one day their parents will die,         one way to rationalize the loss, it does not touch
it does not make it any easier when the time comes.         your emotions.
Few are really prepared for the loss. In some             • Talk to a caring friend, pastor, or counselor. People
instances, friends and associates may criticize the         often say, “My friends don’t want to hear about
adult who grieves the loss of a parent and feel he or       this!” All your friends will not, but ask one or two
she should get on with their lives. The rationaliza-        for permission to use them as sounding boards.
78 coping with the death of a partner/spouse

• Work at keeping the lines of communication open         coping with the death of a partner/spouse In a
  between you and your siblings. They understand          study by psychologists Thomas Holmes and Richard
  more than anyone what your loss entails. Keep in        Rahe, the death of a spouse ranked as the most
  mind that each member of the family has a per-          severe of all problems that people experience. In
  sonal loss and each will mourn the death of your        addition to being traumatic, the death of a partner
  parent for different reasons and in different ways.     or spouse can be especially challenging because it
• Join a bereavement support group.                       touches all aspects of our lives—physical, mental,
• Read books on grief, especially when they are           emotional, financial, and spiritual. The National
  about the death of a parent.                            Mental Health Association explains, “In addition to
                                                          the severe emotional shock, the death may cause a
• Write letters to your parent/parents to express         potential financial crisis if the spouse was the fam-
  your feelings or as a way of saying goodbye.            ily’s main income source. The death may necessitate
• Keep a journal as a record of your own journey of       major social adjustments requiring the surviving
  grief.                                                  spouse to parent alone, adjust to single life and
• Make a “Memory Book” of photos and memen-               maybe even return to work.”
  tos, lighting a candle on special occasions, plant-         Psychologist Helen Greally writes, “Today the need
  ing a tree or shrub in their memory, visiting           for adaptation to this life event is seen as one of the
  special places of significance.                          key factors in coping with the death of a partner or
• Do something to memorialize your parent: a              spouse. Adaptation is a process that takes time—how
  donation to a favorite charity, a memorial in your      that time is used is very important in bereavement.”
  family church, a permanent memorial at his or               Death of a partner during the first 10 years of
  her college or university, or plant a tree in mem-      marriage can present a particular challenge in cop-
  ory of your parent.                                     ing and adapting because not only has the survivor
                                                          lost a spouse, he or she has also lost the future they
• Be patient, tolerant, and gentle with yourself as
                                                          were planning as a couple. At the other end of the
  you grieve. You have experienced a significant loss
                                                          life cycle, another special challenge exists. An eld-
  and you need to take time to grieve. The majority
  of people whose parents die are employed full-          erly couple who have spent most of their adult lives
  time. A three-day bereavement leave is not              married to each other may not be able to imagine
  enough time to deal with this loss. Be aware of         living in the world without their spouse. It will
  the need to adjust your personal schedule to take       mean losing a lifetime of shared experiences. And
  time to grieve.                                         the feelings of loneliness may be compounded by
                                                          the death of close friends. Greally says, “Both of
• Seek professional help when you feel over-
                                                          these bereavements require an enormous amount
  whelmed by your grief or memories. No one has
                                                          of coping, but for different reasons.”
  to bear it all alone. Draw on the resources of your
                                                              The bereaved partner/spouse may experience
  faith to sustain you.
                                                          many different emotions; from initial numbness and
                                                          shock, even when the death was expected, to anger
GriefLink. “Grief Reactions Associated with the Death
                                                          and frustration at the change that has occurred in
   of a Parent.” Available online. URL: http://www.
                                                          his or her life, to an often overwhelming sadness at
   grieflink.asn.au. Downloaded June 16, 2003.
                                                          the seeming unfairness of it all.
Saynor, John Kennedy. “When Your Parent Dies.” Grow-
                                                              The experts suggest several steps to take in cop-
   ing through Grief. Available online. URL: http://
                                                          ing with the death of a loved one, which will help
   www.thefuneraldirectory.com/parents.html. Down-
                                                          get back to a normal routine:
   loaded June 16, 2003.
The USAA Educational Foundation. “Loss of a Loved One.”
   Available online. URL: http://www.usaaedfoundation.    • Accept the reality of your loss.
   org/family/coping/cp03/cp03a.htm. Updated October      • Experience the pain of grief. Recall and reminisce
   29, 2002.                                                about the deceased even to the point of tears.
                                                                               coping with the death of a pet 79

• Adjust to the environment in which the deceased             people as human members of the family. Unfortu-
  is missing; make changes in that environment.               nately, because of pets’ shorter life spans, it is likely
• Exercise daily, even if it’s only a 10-minute walk.         that pet owners will outlive their animal compan-
                                                              ions. Losing a pet can bring about profound grief in
• Avoid using alcohol, drugs, or sleeping pills as
                                                              children and adults alike.
  ways of coping.
                                                                 Coping with the illness, and loss, of a pet can be
• Reinvest in another relationship.                           physically, emotionally, and financially exhausting.
                                                              The pet owner’s emotions can run the gamut from
Greally warns that the death of a partner/spouse is           sadness and anxiety to denial and anger. If the pet
more than losing the physical presence of having              has been debilitated by a fatal or serious disease,
someone always there. It can also mean the loss of            and the owner has chosen to have his or her com-
a friend, soul mate, wage earner, and co-parent.              panion euthanized, feelings of guilt will also have to
Sometimes these losses do not become apparent for             be dealt with.
a while after the death, so it is important for the              The Humane Society of Indianapolis offers the fol-
grieving partner to find good support in the second            lowing suggestions for coping with the loss of a pet:
and third year following the death. But she cau-
tions, “Choose that support wisely. Don’t let your            • Talk to your veterinarian, family members, and
bereavement experience be dictated by others. This              friends—those who shared your pet’s life with
is your grief and you know best how to express it.”             you.
    Hampton and Russell add that “it is preferable to         • Some families may have a burial ceremony or
postpone any major decisions for a year after the               other celebration or remembrance of their com-
death of a mate because the grieving process, which             panion animal’s life.
often lasts a year or more, may cloud a survivor’s
                                                              • You can also express your feelings creatively
judgment.”
                                                                through writing or art.
    An area of loss not always discussed is the physical
side of the relationship, according to Hampton and            • Grief counseling is an option, and there are a
Russell. “Though it is rarely perceived by others, one          growing number of pet-loss support groups. Pet
of the most devastating losses caused by the death of           Loss Hotline volunteers, such as those at Wash-
a spouse is the termination of physical intimacy—               ington State University College of Veterinary
hugging, kissing, tender embraces, all exchanged with           Medicine, are specifically prepared to help people
affection. While sexual activity may be nonexistent             cope with grief and bereavement in the pending
for the survivor, children and family can help to fill           or past loss of a companion pet.
the void in physical contact by themselves embracing,
hugging, and kissing the widow or widower. A touch,                      Explaining Pet Loss to a Child
a quick pat on the shoulder, an affectionate squeeze,         Although parents will naturally want to protect
or a peck on the cheek all can communicate love and           their children from painful experiences, Feinman
help to fill the need for affection.”                          says most adults are surprised to find how well most
                                                              children adjust to the death of a pet if they are pre-
Hampton, Roy F., and Charles Russell. The Encyclopedia of     pared with honest, simple explanations:
   Aging and the Elderly. New York: Facts On File, 1992.
Helen Greally. “Living through the Death of Your Partner or      When a pet is dying, it may be more difficult for a
   Spouse.” The Irish Hospice Foundation. Available online.      child to resolve the grief experienced if the child is
   URL: http://www.hospice-foundation.ie/Leaflet_Death_           not told the truth. Adults should avoid using terms
   of_Partner.htm. Downloaded June 17, 2003.                     like “put to sleep” when discussing euthanasia of a
                                                                 family pet. A child could misinterpret this com-
                                                                 mon phrase, indicating the adult’s denial of death,
coping with the death of a pet      As a source of               and develop a terror of bedtime. Suggesting to a
unconditional love, pets can become as important to              child that “God has taken” the pet might create
80 coping with the death of a sibling

   conflict in the child, who could become angry at           loved ones. When the loved one dies, it may feel as
   the higher power for cruelty toward a pet and the         if part of the self is lost too. When the family is
   child.                                                    secure, and the children feel their home offers a
      Children are capable of understanding, each in         comfortable place for them to retreat to when they
   their own way, that life must end for all living          are hurt, they will probably fare better after the loss
   things. Support their grief by acknowledging their        of a family member.”
   pain. The death of a pet can be an opportunity for
   a child to learn that adult caretakers can be relied                    Death of an Adult Sibling
   upon to extend comfort and reassurance. It is an          THE COMPASSIONATE FRIENDS call adult surviving sib-
   important opportunity to encourage a child to             lings “forgotten mourners,” especially those who
   express his or her feelings                               live away from the family home. “New family roles
                                                             may emerge that might not ever have been consid-
Feinman, Jeffrey. “Coping with the Loss of a Pet.”           ered. A surviving sibling may have to replace a
   HomeVet Natural Pet Care. Available online. URL:          brother or sister as the caregiver for elderly parents;
   http://www.homevet.com/bonding/loss.html. Updated         another may be named as the guardian for surviv-
   July 3, 1998.                                             ing nieces or nephews. Fulfilling these new roles
                                                             can also cause adult siblings to put off dealing with
                                                             their own pain and loss as they embark on their per-
coping with the death of a sibling        Death of a sib-    sonal grief journey. Another aspect of the void may
ling profoundly affects children and has repercus-           find the survivor feeling abandoned by the sibling
sions throughout a child’s life.                             whose role has always been that of the dependable
   Children often engage in “magical thinking,”              ally in times of crisis—ironically, at the time of life’s
believing they have magical powers. When two sib-            worst crisis.”
lings argue, it’s not unusual for one to say (or                Lord offers suggestions for coping with sibling
think), “I wish you were dead.” If that sibling were         death:
actually to die, the surviving sibling might think
that his or her thoughts or statements actually              • Children may find it easier than parents to discard
caused the death.                                              personal possessions of the deceased. They may
   The death of a sibling or other child may be espe-          also find it easier to “put their grief aside” and
cially difficult because it strikes so close to the child’s     find normalcy in school or play.
own peer group. If the child also perceives that the         • During the early days of grieving it is helpful for
death could have been prevented (by either a par-              grieving children to have a personal “ally” to pro-
ent or doctor), the child may think that he or she             vide stability and understanding. This person
could also die.                                                calms the anxious child and relieves the parents
   When a sibling dies after a lengthy illness, ado-           of total responsibility.
lescents, who have resented the sibling for receiving
                                                             • Siblings aged six or seven or older should be
so much attention from the parents while going
                                                               given all the facts about their brother or sister’s
through the illness, may feel guilty.
                                                               death as they become known. Not being told the
   The question of whether the death of a sibling
                                                               truth only enhances a growing sense of being
during childhood or adolescence leads to depres-
sion as an adult is not known. However, Sidney                 unimportant to the family.
Zisook, professor of psychiatry at the University of         • Talk with your surviving brothers and sisters
California at San Diego, says it is clear that what            about both pleasant memories of the child who
happens after the loss is significant in contributing           has died as well as unpleasant memories. This
to or preventing adult depression. “According to               will help them to understand that the child who
current theories of attachment among family mem-               died was not perfect. Placing the dead child on a
bers, children, and even adolescents, cannot always            pedestal can cause great insecurity for surviving
tell the difference between themselves and their               siblings.
                                                                                                  costs of dying 81

“Adolescents Who Are Not Helped with Grief Suffer               corpse flower      Known as Titan arum, a flowering
   Depression as Adults.” Death Care Business Advisor 7,        stalk that can grow as high as 10 feet, and produces
   no. 10 (December 19, 2002).                                  a bloom that opens to a diameter of three to four
Lord, Janice Harris. No Time for Goodbyes: Coping with Sor-     feet. Best known for its strong, putrid smell, Titan
   row, Anger, and Injustice after a Tragic Death. Ventura,     arum emits an odor that has been compared with the
   Calif.: Pathfinders Publishing, 1991.                         smell of rotting flesh and can be detected from half
The Compassionate Friends. “Death of an Adult Sibling.”         a mile away. The odor, which is usually strongest at
   Available online. URL: http://www.compassionate              night, is meant to attract pollinators such as carrion
   friends.org/Brochures/adult_sibling.htm. Downloaded          beetles and flesh flies that are found in the plant’s
   June 17, 2003.                                               native Sumatra, a major island of Indonesia.
Wray, T. J. Surviving the Death of a Sibling: Living through
   Grief When an Adult Brother or Sister Dies. New York:        Jones, Andrew. “Massive ‘Corpse Flower’ Set for Rare
   Three Rivers Press, 2003.                                       Blooming in U.S.” National Geographic News, June 5,
                                                                   2001.

coroners Public officials responsible for investi-
gating any sudden and unnatural death occurring
                                                                cortege    A funeral procession, usually formed at
through violence or under suspicious circumstances.
                                                                the funeral home or place of worship and proceed-
The coroner is likely to come under county jurisdic-
                                                                ing to the cemetery or place of memorial service.
tion. The term coroner has been in use since as early
as the year 900, depending on the historian; it is a
derivation of the word coruner from the root corona,
Latin for crown. They were officers of the crown,                costs of dying A few generations ago, not many
working for the king. Smith says that “coroners                 people lived much beyond 50 years, and it was
started in the late 12th Century. Their job was to              unusual to have a lengthy disability before death.
maintain records of criminal justice and take custody           Most people died from accidents, infections, or child-
of all royal property.” The position has evolved over           birth. The costs of dying were low and mostly cov-
the centuries; today it may be an elected position or           ered by the family. Advances in technology have
appointed and it may require a medical degree or                changed all this. Bossarte explains, “The average age
none at all, depending on state and local laws.                 of death in the 21st century is 78 years. We are now
   Smith explains, “In determining the cause of                 most likely going to die from cancer, heart disease,
death, the coroner holds an inquest (from the Latin             stroke or dementia. We will be disabled by our ill-
to seek into) whenever there is doubt. He or she                nesses, on average, more than four years. And dying
may be assisted by a jury. In several states the coro-          costs us more because of the length of disability and
ner, who may or may not be a physician, counts on               the costs of interventions and medications to extend
the MEDICAL EXAMINER, a pathologist with forensic               life or relieve pain and suffering. Most of us will not
training whose activities may be restricted to post-            be able to pay for our own health care and will rely
mortem examinations.” The coroner determines the                on Medicare and Medicaid programs.”
cause of death for the police investigation.                        According to The Wall Street Journal, one in every
                                                                seven dollars spent on health care is spent during
Smith, Ian Maclean. “Coroners Provide Essential Commu-          the last six months of life. Figures from 2000
  nity Service.” Virtual Hospital, University of Iowa. Avail-   showed that end-of-life costs account for about 10
  able online. URL: http://www.vh.org/adult/patient/            percent of total health care spending and 27 percent
  internalmedicine/aba30/1999/coroners.html. Posted             of Medicare expenditures. Others have reported as
  February 1999.                                                much as half of all health care dollars are spent in
                                                                the last six weeks of life.
                                                                    Senior citizens near the time of their death can
corpse    The dead body of a human being.                       expect to generate more than $50,000 in medical,
   See also NECROPHILIA; NECROPHOBIA.                           funeral, and burial costs, according to figures
82 counseling

released in August 2002 by the National Center for             of life. It showed that the decedents who got
Policy Analysis (NCPA). The government will pick               aggressive care were the younger (under 80
up about 65 percent of the cost through subsidized             years) decedents who were in good functional
programs such as Medicare and Medicaid, which                  condition, whereas the frail older old were given
are funded by taxpayers. When baby boomers begin               mainly supportive care.
to retire in a few years, NCPA research shows that           • Most of the savings were achieved in the last
the cost of dying will soar.                                   month of life by hospice patients with a stay of
   Most of the costs of dying are hidden. According            less than three months, whereas patients enrolled
to the NCPA:                                                   for more than three months did not save the
                                                               Medicare program any money, except possibly
• Medicare averages the spending of $28,616 on                 beneficiaries enrolled for six to seven months,
  medical bills for seniors in the last two years of life.     the longest enrollment period.
• Medical costs paid by Medicaid and private insur-          • Only a handful of studies have explored the ques-
  ance average $4,006 and $3,720, respectively.                tion of whether advance directives (or DNR orders)
• The deceased and their families can expect out-              lower the terminal medical (usually inpatient
  of-pocket medical expenses of $5,723.                        hospital) costs of patients who die. To date, how-
                                                               ever, the findings of these studies are inconclusive.
• Funeral and burial expenses average another
  $8,000.                                                    • In the many studies of medical care costs at the
                                                               end of life, the emphasis has been almost exclu-
The Robert Wood Johnson Foundation funded an                   sively on high-cost, high-technology care. Largely
in-depth critical review of the literature published           ignored has been the problem of patients dying in
during the 1980s and 1990s on high-cost illness and            nursing homes. Considering that such patients
methods to reduce these costs, such as hospice care            also have additional medical expenses—for physi-
and advance directives for medical care. Among its             cian and at least some hospital services, and for
key findings:                                                   drugs—it is clear that many patients who die in
                                                               nursing homes have catastrophic expenses. As
• Although changes in medical technology and                   the population ages, this group of decedents will
  greater intensity of care have contributed to the            become increasingly important and may well
  overall rise in medical care costs, the cost ratio of        pose greater economic problems than the high-
  seven times higher for those elderly Medicare                cost decedents on whom most of the research to
  patients who died than for those who survived                date has focused.
  has remained constant over past decade.
                                                             Bossarte, Raeann. “End of Life.” Senior News 19, no. 11
• Costs at the end of life vary widely between dif-            (November 2000).
  ferent causes of death. Deaths from malignant              Robert Wood Johnson Foundation. “Monograph on High-
  neoplasms, nephritis, COPD (chronic obstructive              Cost Illness at the End of Life.” Available online. URL:
  pulmonary disease), and chronic liver disease are            http://www.rwjf.org/reports/grr/021577s.htm. Last
  the principal high-cost causes of death in terms             updated April 1998.
  of per capita Medicare payments at the end of
  life. By contrast, deaths from heart disease and
  cerebrovascular disease are at the opposite end of         counseling Individuals who continue to suffer
  the scale. However, these data refer to Medicare-          from the stresses of grief for a long period of time
  covered services, and do not include costs of long-        may find mental health counseling helpful. Getting
  term care.                                                 help when it is needed is a sign of strength and wis-
• One small study suggests that functional status            dom; appropriate referrals for mental health help
  (in addition to age) plays an important role in            can be obtained from a social worker or a physician.
  determining the intensity of care in the last year         Support groups for widows and widowers, parents,
                                                                                                     cremation 83

and divorcees are effective for many people. Know-           posing of bodies in Greece by 800 B.C.E. and in
ing that others had the same emotional reactions             Rome 600 B.C.E. But the custom was not embraced
can help participants cope better with their grief           by early Christians, who considered it pagan,
stressors. Those grieving for the loss of a child may        because of their doctrine of bodily resurrection. So
also find help in appropriate support groups.                 as Christianity spread across Europe, burial replaced
                                                             cremation except in times of plague or war.
Kahn, Ada P. “Grief,” in Stress A to Z. New York: Facts On       Modern cremation did not begin until the late
  File, 1998.                                                19th century when an Italian, Professor Brunetti,
                                                             developed the first modern cremation chamber in
                                                             the 1870s. This triggered a movement toward cre-
cremains     After the cremation process, the                mation in Europe and North America, which has
remains are a combination of ash and bone frag-              continued to the present day. Except for two
ments, which are then processed further to create a          recorded instances prior to 1800, cremations in
uniform powderlike texture. The common term for              North America did not begin until 1876 when Dr.
them is ASHES. As cremating becomes more com-                Julius LeMoyne built the first crematory in Wash-
mon, the traditions of what to do with the cremains          ington, Pennsylvania.
are changing. Scattering remains is declining in                 In 1886 the Roman Catholic Church officially
favor of more lasting (and more expensive) alter-            banned cremations. Church members as recently as
natives. Among the more creative ways families are           World War II were excommunicated for arranging
“storing” their loved one’s cremains are in crema-           them. Most religions today allow cremation except
tion benches, jewelry, keepsake urns, sculptures.            for Orthodox Jewish, Islamic, Eastern Orthodox,
Other families have paid thousands of dollars to             and a few Fundamentalist Christian faiths. The
send their cremains into space in order to be scat-          Roman Catholic Church lifted the ban forbidding
tered there.                                                 Catholics to choose cremation in 1963. This per-
                                                             mission was incorporated into the revised Code of
                                                             Canon Law of 1983 (Canon #1176), as well as into
cremation     The word cremation comes from the              the Order of Christian Funerals. Nearly all Protes-
Latin word cremo, which means “to burn,” particu-            tant churches allow for the urn to be present during
larly the burning of the dead. Cremation is a process        the memorial service. Most Catholic churches also
of reducing the human body to bone fragments                 now allow the cremated remains to be present dur-
using high heat and flame. These fragments are               ing the Memorial Mass, although the church prefers
called cremated remains or CREMAINS; they have               that cremation take place after the full funeral
neither the appearance nor the chemical properties           liturgy with the body if it is possible. State laws vary,
of ASHES, the term most people use for them. These           but generally when a deceased body is not cremated
remains can then be buried in a cemetery lot or cre-         within 24–48 hours, it must be embalmed the same
mation garden, kept in an URN in a COLUMBARIUM,              as a body to be buried.
kept at home, or scattered. Laws vary from state to              Roman Catholic law does not allow for the scat-
state as to how and where they may be disposed.              tering of ashes. “The practice of scattering cremated
Cremation is not a substitute for a funeral. It is sim-      remains on the sea, from the air, or on the ground,
ply a method of preparing the deceased for burial            or keeping cremated remains in the home of a rel-
and/or memorialization.                                      ative or friend of the deceased are not the reverent
    Most archaeologists agree that cremation began           disposition that the Church requires.” (Order of
during the early Stone Age, about 3000 B.C.E. It             Christian Funerals, Appendix II: Cremations). How-
likely was first used in Europe and the Near East,            ever, the church does allow burial at sea of ashes
then during the late Stone Age began to spread               that have been placed in an appropriate container
across northern Europe. By 1000 B.C.E. cremation             that is heavy enough to sink to a final resting place.
had become an important part of Grecian burial                   In addition to religious questions, medical issues
rites, and became the most common method of dis-             also need to be considered when deciding between
84 cremation

cremation and burial. As researchers learn more           at one time. The length of time the cremation
about genetics, documenting and retrieving DNA            process takes depends on the weight of the individ-
will become more important in studying, treating,         ual. For an average size adult, cremation takes from
and preventing diseases that tend to run in families,     two to five hours at normal operating temperatures
such as Alzheimer’s, cancer, diabetes, heart disease,     of between 1,400°F and 2,100°F. After cremation is
and multiple sclerosis. The thorough reduction and        completed, a cooling period is required prior to the
fragmentation of cremated human remains often             recovery of the cremated remains.
leaves little biological evidence of diagnostic value.        All organic bone fragments, which are very brit-
    The number of cremations in North America has         tle, as well as non-consumed metal items are
increased dramatically in recent years: from 5 per-       “swept” into the back of the cremation chamber and
cent in 1962 to 20 percent in 1992. In 2000 26 per-       into a stainless steel cooling pan. All non-com-
cent of Americans and 45 percent of Canadians             bustible items, such as metal from clothing, artificial
were cremated. Based on the past five years’ aver-         joints (such as hip joints), bridge work, casket
age percent change, the Cremation Association of          hinges, and jewelry, are separated from the cremated
North America projects that in 2010, 31 percent of        remains. This separation is accomplished through
deceased Americans will be cremated and 47 per-           visual inspection as well as using a strong magnet for
cent of Canadians, and in 2025, 49 percent of             smaller and minute metallic objects. Items such as
deceased Americans. According to the Cremation            dental gold and silver are non-recoverable and are
Society of Great Britain, in the year 2000, crema-        commingled in with the cremated remains. Remain-
tions took place in 71 percent of all funerals there.     ing bone fragments are then processed in a machine
In other countries, such as Japan and Scandinavia,        to a consistent size and placed into a temporary con-
cremations reach as high as 95 percent.                   tainer, unless a permanent urn has been selected by
    People choose cremation for a variety of reasons.     the family. Cremated remains resemble coarse sand
Because neither an expensive casket nor embalming         and are whitish to light gray in color. The remains of
are required, it is usually less costly, so some choose   an average size adult usually weigh between four to
it for the financial savings. Unless the ashes are        six pounds and take up a space of approximately
buried, there is no cost associated with the purchase     150–200 cubic inches; remains can weigh from three
and perpetual care of a grave site or tombstone.          to nine pounds. Some crematories process the cre-
Also, with less cemetery space available today, some      mated remains in order to reduce the space they
consider cremation due to environmental concerns.         require. The remains, in their container, are returned
Others choose cremation because it allows scatter-        to the family or transported to a location (such as a
ing of the remains in a place of significance to the       funeral home or church) specified by the family.
deceased.                                                     When ashes are to be transported across state
    In preparation for cremation, the body is placed      lines, the airline or other carrier, or the departments
into a wooden box or casket (container), which is         of health for the states involved, need to be con-
consumed along with the body. When desired, some          tacted, because some states regulate the transport of
crematoria will allow a small number of personal          cremated remains.
items to be placed with the deceased prior to cre-            On February 24, 2000, the U.S. Postal Service
mation. These items will remain with the deceased         issued Postal Bulletin 22018 to remind postal
and will be consumed during the cremation process.        employees “that human remains (e.g., an urn with
Because of the explosive potential of pacemakers          ashes) must be sent as registered mail with return
when heated, they must be removed prior to cre-           receipt services. Employees who do not enforce this
mation. Radioactive implants may also pose poten-         regulation risk putting the Postal Service in the
tial health hazards to crematory personnel, and so        uncomfortable position of losing or delaying these
are removed prior to cremation. Artificial joints are      items, possibly at great emotional distress to fami-
not removed before cremation. The container is            lies of deceased persons.” Cremated remains cannot
placed in a chamber called a retort. Each retort is       be sent by overnight express mail, regular mail, or
large enough to hold only one cremation container         certified mail.
                                                                                                criteria of death 85

   In recent years several scandals have hit the cre-         • Cremated Remains Disposition—Delivered to
mation industry—the discovery of 339 remains that               Cemetery 40.7%; Taken Home 35.8%; Scattered
were not cremated at the Tri-State Crematory in                 as Directed 17.8%; Not Picked Up 5.7%
Georgia, the detour of remains from a crematorium             • Of Those Delivered to a Cemetery—Buried
to Lynn University’s funeral service program in                 56.8%; Placed in Columbarium 25.6%; Scattered
Florida, and the selling of body parts by Pacific Cre-           on Dedicated Property 15.2%; Placed in Com-
mation Care in California. Although such scandals               mon Grave 2.4%
have not slowed the number of cremations, the
                                                              • Of Those Scattered as Directed—Over Water
industry reports that more people now want to
                                                                72.7%; On Land 27.3%
accompany the body through the cremation
process. To facilitate this, some crematories are             • Service Held Prior to Cremation—Yes 67%; No 33%
adding viewing rooms that overlook the retort. As             • Memorial Service Held after Cremation—No
family members watch, the funeral director opens                56.3%; Yes 43.7%
the cremation box so the family can see that it con-
tains the remains of their loved one, and then they           Gale, C. P., and G. P. Mulley. “Pacemaker Explosions in
watch as the box is pushed into the retort. Such                 Crematoria: Problems and Possible Solutions.” Journal
monitoring of the cremation process has always                   of the Royal Society of Medicine 7 (July 1995): 353–355.
been possible, but was not often requested. Because           Rutherford, Richard. Honoring the Dead: Catholics and Cre-
of the scandals, requests have increased.                        mation Today. Collegeville, Minn.: Liturgical Press
   Death Care Business Advisor, an industry newsletter,          (2001).
reported in July 2002 that a Texas crematory                  Warren, M. W., and J. J. Schultz. “Post-cremation Taphon-
designed a system that allows families to track the              omy and Artifact Preservation.” Journal of Forensic Sci-
remains. It works like the tracking systems used by              ences 47 (May 2002): 656–659.
United Parcel Service, the U.S. Postal Service, and
Federal Express. The system requires the funeral
director to use a biological access point, such as a facial   crematory      Also called crematorium. An estab-
scan or fingerprint scanner, to make sure the cre-             lishment where CREMATION is performed. Some peo-
mation is carried out on the correct person. The sys-         ple use it to denote a furnace where a corpse can be
tem then tracks when the body is taken to the                 burned and reduced to ashes.
crematory, who signs it in, who puts it in refrigera-
tion, when it is put into the retort and when the cre-
mains are put in a special locker. The family signs off       crib death     See   SUDDEN INFANT DEATH SYNDROME
on it when they get a full report, and can demand to          (SIDS).
see the audit trail at any time.
   In 1997 the Cremation Association of North
America conducted a survey to collect statistical             criteria of death Dramatic progress in the devel-
information on crematory operations in the United             opment of medical apparatus and of treatments
States and Canada. Among its findings:                         required to support life have made it possible to
                                                              maintain body functions even after mental func-
• Median age of cremated bodies—74.0 years                    tions have ceased irreversibly. In order to deal with
• Gender—Female 51.9%; Male 48.1%                             the consequent problems, a Harvard University Ad
                                                              Hoc Committee on the Examination of the Defini-
• Race and Ethnicity—Caucasian 88%; African
                                                              tion of Brain Death in the late 1960s proposed a
  American 6%; Asian 3%; Hispanic 3%
                                                              new definition of death, which has obtained
• Religious Affiliation—Protestant 58%; Catholic               increasing acceptance: the criterion of death has
  26%; Buddhist 11%; Jewish 3%; Hindu 2%                      been reached when the recorded brain function has
• Body Cremated in—Alternative Container 80.2%;               ceased for a 24-hour period. In recent years an addi-
  Wood Casket 8.3%; Cloth Covered Casket 7.2%                 tional criterion has been added: death occurs when
86 cryonics

circulation within the brain, recorded by one of the           cryonically preserve the Splendid Splinter’s body.
modern medical techniques, has ceased.                         The Williams “preservation” also renewed a feud
    The UNIFORM ANATOMICAL GIFT ACT has been                   among scientists over whether the process is quack-
criticized for a lack of criteria for determining the          ery or innovation. A spokesman for a Georgia com-
moment of death. As the law stands, one doctor is              pany that freezes human valves and veins for heart
required to determine the moment of death. This                surgeries and other procedures, stated in The Atlanta
doctor is not allowed to participate in the process of         Journal and Constitution that “Right now, it is impos-
removing or transplanting donor parts. Other coun-             sible to effectively cryopreserve a whole organ, let
tries, such as France, Czech Republic, and Portugal,           alone a whole body.” Barry Shur, chairman of cell
require two doctors to determine the time of death             biology at Emory University, added, “To take tissue
as a protection for the donor. Some states, including          that has expired—deteriorated, with metabolic
California, Virginia, and Kansas, have included                decay products and toxins produced—and then
statutes that specify the moment of death as the               freeze it with the intent you could correct the reason
time of brain death.                                           for the death in the first place and overcome that by
    In Norway, death is defined as the total and irre-          thawing out the tissue has no scientific basis.”
versible damage of the whole central nervous sys-                 Yet families have paid as much as $120,000 to
tem. This means that the time of death is some                 cryopreserve deceased family members. There is
minutes after circulatory arrest. The time lapse may           also a Washington, D.C.-based Life Extension Soci-
vary from about five minutes up to 45 minutes,                 ety devoted to the cryogenic freezing of members’
depending on the temperature in the brain when                 bodies when they die.
the circulation ceased.
    Weber writes, “The state of New Jersey allows              Reel, Monte. “Frozen for the Future: Area Cryonics Buffs
individuals to determine which criteria of death will            Talk of Renewing Life and Wait for Thaw in Public’s
be applied in their case. If one does not agree with             Attitude.” The Washington Post, July 22, 2002.
the consensus that death occurs when the entire                Wahlberg, David. “Ted Williams: 1918–2002: Freezing
brain irreversibly ceases functioning, then one may              Viewed Skeptically.” The Atlanta Journal and Constitu-
stipulate that his or her death be declared when                 tion, July 9, 2002.
cardiopulmonary functioning irreversibly ceases.”

Roy, F. Hampton, and Charles Russell. “death,” in The          crypt    An underground vault or chamber used for
   Encyclopedia of Aging and the Elderly. New York: Facts On   burial, especially under a church.
   File, 1992.
Sardegna, Jill, and T. Otis Paul. “Uniform Anatomical Gift
   Act,” in The Encyclopedia of Blindness and Vision Impair-   culture and death Culture can be defined as a
   ment. New York: Facts On File, 1991.                        unified set of values, knowledge, ideas, beliefs, and
Weber, Leonard J. “The Patient as Citizen.” Health Progress.   standards of behavior shared by a group of people.
   Available online. URL: http://www.chausa.org/PUBS/          The influence of culture on the meaning and expe-
   PUBSART.ASP?ISSUE=HP9306&ARTICLE=A. Down-                   rience of death and dying may be applied to aspects
   loaded July 13, 2004.                                       of end-of-life care, such as symptom management,
                                                               advance-care planning, and grief and bereavement
                                                               counseling, according to Crawley et al.
cryonics    Body preservation through the ultra-cold              As the number of cultures within the United
temperature of liquid nitrogen and below—also                  States multiplies, health care providers need to be
called cryonic suspension or cryonic stasis or cryop-          familiar with multicultural attitudes toward death
reservation—until a time when it can be resusci-               and bereavement. Even though legislation, health
tated. Cryonics became a hotly discussed topic                 regulations, customs, and work rules have greatly
following the death of Ted Williams, one of the all-           influenced how death is managed in the United
time great baseball players, when his son filed suit to         States, bereavement practices vary in profound
                                                                                                     cyanosis 87

ways depending on one’s cultural background. Grief      • Latino/Hispanic Americans highly value receiv-
counselors advise that when assessing an individ-         ing services from the family, with the extent and
ual’s response to the death of a loved one, clini-        utilization of informal networks varying between
cians unfamiliar with a culture should inquire about      different subgroups. Latino/Hispanic elders often
customs, beliefs, or cultural norms, and appreciate       believe that if the family cannot provide care, they
what is expected or required by the person’s culture.     are not fulfilling their responsibility. Such beliefs
Failing to carry out expected rituals can lead to an      reinforce the need to involve the family exten-
experience of unresolved loss for family members.         sively in the planning and delivery of services.
This is often a daunting task when health care pro-     • American Indians/Native Americans rely on the
fessionals serve patients of many ethnicities.            extended family system, especially for tribal groups
    The establishment culture in America expects          who still live on reservations. They treat the issue
that patients will be told the truth regarding a ter-     of death and dying in a way similar to other Amer-
minal illness or a poor prognosis. Some ethnic            ican ethnocultural groups, that is, to speak about
American groups perceive and manage end-of-life           death may cause it to happen. Therefore, issues
issues differently. Surveys show that many ethnic         like advance directives often are not discussed.
and Native Americans would not want to be told
distressing news about their health. As a result, our   Thomas emphasizes that helping patients to “die
bias in favor of truth-telling risks alienating these   well” will not occur “unless we have a better under-
patients and their families.                            standing of the role that culture plays throughout
    Thomas writes, “Fundamental philosophical dif-      the course of one’s life.”
ferences exist between ‘Western’ thinking and that
of terminally ill persons who are African American,     Candib, Lucy M. “Truth Telling and Advance Planning at
American Indian/Native American, Asian Pacific             the End of Life: Problems with Autonomy in a Multi-
Islander, and Hispanic/Latino. For them, care of the       cultural World.” Families, Systems & Health 20, no. 3
terminally ill focuses on living and prolonging life;      (September 2002): 213–228.
Western thinking focuses on helping people cope         Crawley, LaVera M., et al. “Strategies for Culturally Effec-
with their eventual death.”                                tive End-of-Life Care.” Annals of Internal Medicine 136,
    Among the differences among cultures cited by          no. 9 (May 2002): 673–679.
Thomas:                                                 Thomas, Norma D. “The Importance of Culture Through-
                                                           out All of Life and Beyond.” Holistic Nursing Practice 15,
• African Americans do not plan for death in the           no. 2 (January 2001): 40–46.
  sense of advance directives and living wills.
  Rather, they tend to utilize home remedies before
  formal systems and believe that church and fam-       cyanosis     A bluish-grayish discoloration of the
  ily, as opposed to formal providers, should pro-      skin and mucous membranes (such as the lips),
  vide service at the terminal stage.                   caused by a lack of oxygen in the blood. Cyanosis
• In many Asian cultures it is believed that talking    may appear prior to death as the circulatory system
  about bad things will produce bad outcomes.           becomes impaired. David Kessler, writing in The
  Consequently, an Asian-American family may be         Needs of the Dying (HarperCollins, 2000), explains
  very reluctant to have a health care practitioner     that “since our loved ones are usually close to death
  inform the patient of a terminal diagnosis, even      at this point and are unaware of the cyanosis, it is
  though in an American cultural framework the          typically only the caregivers who notice the change.
  person has a “right to know.”                         This is a normal part of the dying process.”
                                                                                                                D
Day of the Dead       A festival celebrating the dead in        cessation of electrical activity in the brain as deter-
Mexico; it is held the first two days of November.               mined by EEG; manifestation of rigor mortis.
The holiday represents a blend of Catholic and                     In the past it was customary to attribute non-
indigenous traditions. Spirits of the dead are believed         accidental death to “natural causes,” which were
to return to their homes and to visit for a short time          thought to bring about a termination of life as if by
with their families and friends. The first day of               unavoidable destiny and with no particular cause
November the souls of departed children arrive, and             specified. Since the early 1900s, however, death has
on the second day they are joined by spirits of adults.         no longer been thought to happen unavoidably
   Families open their homes to visitors, offering              without specific cause. Today, physicians who fill
them food, drink, stories, memories, and goodwill.              out death certificates usually must enter a specific
To celebrate, the families make altars and place offer-         disease or condition that caused the death.
ings of special food such as “pan de muertos” (sweet               In spite of the long precedent in recording a
bread baked in shapes of skulls and skeletons). A               cause, or causes, for death, enormous advances in
photo of the departed soul is placed on the altar. In           medical science in the last 30 to 50 years have made
some towns, school classes, government employees,               the medical meaning of the term “death” itself
and artists compete for the most creative and inter-            increasingly ambiguous. Death used to be signaled
esting altar. Sometimes people leave candles and                when the vital functions of a person, especially
sweets on the graves for dead children. When the                breathing and circulation of the blood, had ceased.
candles flicker, it is taken as a sign that the children         Today, however, dramatic progress in the develop-
have come and taken the essence of the sweets.                  ment of medical apparatus and treatments required
   The ancient festival was originally dedicated to             to support life have made it possible to maintain
the goddess Mictecacihuatl (Lady of the Dead) and               body functions even after mental functions have
was celebrated in late July or early August. The feast          ceased irreversibly. In order to deal with these prob-
was moved to All Hallows Eve by Spanish priests,                lems, a Harvard University Ad Hoc Committee on
but the original tone and exuberance, despite the               the Examination of the Definition of Brain Death in
best efforts of those priests, remained the same.               the late 1960s proposed a new definition of death,
   The Day of the Dead is also celebrated in Peru, on           which has obtained increasing acceptance: the cri-
November 2, when the dead come alive and leave                  terion of death has been reached when the recorded
their Andean graveyards with their high walls and               brain function has ceased for a 24-hour period. In
gates.                                                          recent years an additional criterion has been added:
                                                                death occurs when circulation within the brain,
                                                                recorded by one of the modern medical techniques,
death Permanent cessation of all vital functions;               has ceased.
total, irreversible cessation of cerebral function,
spontaneous function of the respiratory system, and             Roy, F. Hampton, and Charles Russell. “Death,” in The
spontaneous function of the circulatory system;                   Encyclopedia of Aging and the Elderly. New York: Facts On
final and irreversible cessation of perceptible heart-             File, 1992.
beat and respiration. Indicators of death include the           Watstein, Sarah Barbara. “death,” in The AIDS Dictionary.
cessation of the heart’s action; absence of reflexes;              New York: Facts On File, 1998.
                                                           89
90 death agonies

death agonies     Muscle spasms that often occur             higher on the Fear of the Dead subscale of the Mul-
immediately prior to the moment of clinical death.           tidimensional Fear of Death Scale (MFODS) than
Also called the agonal moment, the term comes                did men. Caucasian participants displayed higher
from the Greek agon, connoting a struggle. In How            Fear of the Dying Process than did older African-
We Die: Reflections on Life’s Final Chapter (Vintage         American participants. Lastly, older African-American
Books, 1993), Nuland says, “The dying person is              participants reported higher levels of death anxiety
too far gone to be aware of them. Agonal moments             on three of the subscales of the Multidimensional
and the entire sequence of events of which they              Fear of Death Scale (Fear of the Unknown, Fear of
are a part can occur in all the forms of death,              Conscious Death, and Fear for the Body after Death)
whether sudden or following upon a long period of            when compared with older Caucasian participants
decline into terminal illness, as in cancer.” Those          and also tended to accord less social value to the
other events can include gasping breaths or brief            elderly.
convulsions.                                                    See also THANATOPHOBIA.

                                                             Bruns, Daniel. “Matters of Life and Death.” Health Psy-
death anxiety    Death anxiety is a potentially dis-            chology & Rehabilitation. Available online. URL:
ruptive concern about death and dying. It is a mul-             http://www.healthpsych.com/Lifeanddeath.html.
tifaceted concept and can include fears about the               Posted in 1997.
process of dying, death itself, and what happens             Depaola, S. J., et al. “Death Anxiety and Attitudes toward
afterward. Studies show that the height of death                the Elderly among Older Adults: The Role of Gender
anxiety occurs in people’s 40s and 50s, when they               and Ethnicity.” Death Studies 27, no. 4 (May 2003):
begin to calculate how many years they have left.               335–354.
    Bruns compares death anxiety to a deer caught
in headlights:
                                                             deathbed   The last few hours before death; also,
  Nowhere is death anxiety seen more clearly than in         the bed on which a person dies.
  patients suffering from terminal or potentially ter-
  minal conditions. Facing one’s own mortality is a
  frightening experience. In response to even the pos-       deathbed statement       Also called dying declara-
  sibility of a diagnosis of a terminal condition, some      tion. Statement made by a person who believes he
  people respond the way a deer does at night to the         or she is about to die, concerning the cause or cir-
  oncoming headlights of a car. They freeze, and their       cumstance surrounding his or her impending death.
  very inability to act may further jeopardize them.         Although hearsay (because the dead person cannot
  Death anxiety, when experienced, has a way of              testify in person), a deathbed statement is admissi-
  stopping one in one’s tracks. It shreds the fabric of      ble in court on the theory that a dying person has
  one’s life, and turns it inside out. In an instant, mat-   no reason not to tell the truth.
  ters that had seemed important become trivial, and
  a person can become disoriented by it all.
                                                             deathbed visions (DBV)      A phenomenon whereby
Depaola et al. investigated the relationship among           a dying person has an awareness of the presence of
death anxiety, attitudes toward older adults, and            dead relatives or friends. According to researcher
personal anxiety toward one’s own aging in a group           Carla Wills-Brandon, “Deathbed visions are a dif-
of 197 older men and women. Negative attitudes               ferent phenomenon than after-death visitations.
toward other older adults were predicted by per-             After-death visitations are visions of deceased loved
sonal anxieties about aging and death, and, more             one(s) by people who are not near death. DBVs
specifically, fear of the unknown. In addition, sev-          usually occur when someone is very close to death
eral distinctive anxieties were noted for particular         and they see visions of deceased loved ones who
subgroups of respondents. Older women scored                 greet them to help the dying make the transition of
                                                                                           death certificate 91

death. These experiences can even take the form of             According to Hermanson’s research, there are
NEAR DEATH EXPERIENCES. DBVs can occur even days           currently in the United States more than 22,000
before a person dies. Many terminally ill people will      funeral homes, approximately 115,000 cemeteries,
experience these visitations to help prepare them          1,155 crematories, and an estimated 300 casket sell-
for when they cross over to the other side. DBVs           ers (which are neither funeral homes nor cemeter-
also occur to family members in the vicinity of a          ies). Changes in the industry include an increase in
dying loved one to reassure them that their dying          preneed agreements, cremations, and the number
loved one will be safe and will live on.”                  of large chains. In addition, there is a blurring of the
   When Houran and Lange analyzed 49 accounts              traditional distinctions between the funeral and
of deathbed visions from a classic collection, their       burial industries, and between for-profit and non-
findings were consistent with the interpretation that       profit cemeteries.
deathbed visions are comforting hallucinations.                Funeral homes and third-party sellers are nearly
                                                           all for-profit businesses. Most cemeteries are non-
Houran, J., and R. Lange. “Hallucinations That Comfort:    profit; however, many for-profit businesses have
   Contextual Mediation of Deathbed Visions.” Perceptual   close connections with nonprofit cemeteries. Her-
   and Motor Skills 3, no. 2 (June 1997): 1491–1504.       manson explains, “Some chains have established a
Wills-Brandon, Carla. “Deathbed Visions.” Near-Death       nonprofit corporation as the titular owner of the
   Experiences and the Afterlife. Posted online. URL:      cemetery to meet statutory requirements. For
   http://www.near-death.com/deathbed.html. Down-          example, in Oklahoma, all cemeteries are required
   loaded June 23, 2003.                                   to be nonprofit, and yet at least 25 are owned by a
                                                           for-profit chain.”
                                                               Horn also notes that chains are coming to domi-
death benefit The amount payable to a benefici-              nate the $25 billion industry, with three major
ary from an annuity or insurance policy when the           chains owning 15 percent of the country’s funeral
policyholder dies. Also called the survivor benefit.        homes and two companies handling two-thirds of
                                                           all casket and urn sales.

death camp     A concentration camp in which those         Hermanson, Sharon. “The Deathcare Industry.” AARP
held captive are likely to die or be killed. Also, mil-      Public Policy Institute Research Group. Available
itary prisons having a very high death rate, such as         online. URL: http://research.aarp.org/consume/ib44_
Andersonville in Georgia and Elmira in New York              deathcare.html.
during the Civil War. The term death camp has              Horn, Miriam. “The Deathcare Business: The Goliaths of
become synonymous with Nazi concentration                    the Funeral Industry Are Making Lots of Money Off
camps in which mass executions of Jews were car-             Your Grief.” U.S. News & World Report, March 23, 1998.
ried out by means of gas; the most notorious camp
was at Auschwitz in Poland.
                                                           death certificate A document proclaiming the
                                                           death of an individual. The death certificate is a civil
death care industry Name by which the funeral              law document, not a medical science document,
industry prefers to be called, although some are           and is specific to each state, but based on a national
now using a more politically correct “post-life            standard form. The death certificate is a public
industry.” The term refers to a range of providers of      record intended to inform the public and be uti-
burial goods and services, from the traditional trio of    lized by a variety of agencies. A death certificate
main sectors (funeral homes, cemeteries, and mon-          generally indicates the place of death and cause of
ument retailers) to a variety of subsectors of third-      death, i.e., natural, accidental, homicide, or suicide;
party sellers (casket manufacturers, florists, vault        it may also list significant conditions contributing to
suppliers, crematories, pre-need insurance, and            death, but does not usually include the modes or
even companies that scatter ashes at sea).                 mechanisms of death. Conditions that existed, but
92 death education

that did not contribute to death, are not entered.       and zip code; method of disposition, date pro-
Doctors will usually complete a death certificate,        nounced dead, time pronounced dead, date of
though sometimes coroners are needed to investi-         death, time of death, cause of death; was an autopsy
gate deaths or act in lieu of a physician. Although a    performed, were autopsy findings available to com-
legal document, entries on the death certificate are      plete the cause of death, did tobacco use contribute
not legally binding for any agency or individual.        to death; manner of death certifier (certifying
Evidence may establish that the cause of death was       authority identifies the manner or how the
misclassified or that the circumstances of the partic-    deceased died); date of injury, time of injury, place
ular case justify a finding that the death was acci-      of injury (type of place where injury occurred),
dental. One analysis of 494 death certificates found      injury at work, location of injury (geographic loca-
that more than 40 percent were improperly com-           tion where injury occurred); description of how
pleted. Another found that not a single death certifi-    injury occurred, if transportation accident, specify;
cate out of 69 studied listed the correct underlying     decedent’s education. The 261-page specifications
cause of death.                                          can be downloaded at http://www.cdc.gov/nchs/
    Experts suggest that the next of kin obtain eight    data/dvs/dallspec122002-updated.pdf.
to 10 certified copies of the death certificate, which
will be needed as proof of death for closing out legal
affairs, such as insurance, Social Security, VA bene-    death education      Beginning in the 1980s, schools
fits, real estate, or banking. A death certificate also    across the country began to offer courses on death
must accompany the body if it is transported to          and dying. The actual number of such courses is not
another state.                                           known, according to Evans and Farberow, because
    In addition to providing legal proof that a person   death education is often presented as a part of
has died, a death certificate also provides data that     more-traditional courses.
public health officials use to measure the nation’s          Proponents of death education say it is beneficial
health and help decide on funding amounts for            and long overdue. Critics, on the other hand, claim
medical research. Information from death certifi-         such courses are often introduced haphazardly by
cates is also used by actuaries to determine insur-      unqualified teachers and point to cases of negative,
ance rates. Guidelines for death certification are       damaging end results as information impacts upon
established by the National Center for Health Sta-       young people.
tistics of the Centers for Disease Control and Pre-         Medical textbooks offer little information on
vention (CDC) and each state’s health statistics         end-of-life care, according to a University of Cali-
department. The CDC states that “the cause-of            fornia at San Francisco (UCSF) study. Published in
death section in the medical-legal officer’s certifica-    the February 9, 2000, issue of the Journal of the
tion is always an opinion. It represents the best        American Medical Association, the study found that of
effort of the medical-legal officer to reduce to a few    the 50 textbooks reviewed, about a quarter had
words his or her entire synthesis of the cause of        helpful information on likely end-of-life subject
death; and a best estimate of the manner of death        areas, but 19 percent gave the subject minimal
and the time and date of injury may also be required     attention and 57 percent none at all.
when neither investigation nor examination of the           The textbooks that most lacked end-of-life con-
deceased provides definitive information.”                tent were in survey, infectious diseases, AIDS, and
    In 2003 the CDC proposed a revision of the U.S.      oncology. Textbooks with the highest percentage of
Standard Certificate of Death in order to facilitate      helpful end-of-life care content were in family med-
electronic gathering of those statistics and make        icine, geriatrics, and psychiatry.
them more useful. The revision proposes gathering           According to the UCSF authors, medical educa-
nearly 50 pieces of information: decedent’s legal        tion typically provides little training in care for the
name, sex, Social Security number, age, date of          dying, likely contributing to both deficient care for
birth, birthplace, residence, marital status, father’s   the dying patients and increased anxiety for caring
surname, place of death; facility name, city, town,      physicians.
                                                                                                     death rate 93

Evans, Glen, Norman L. Farberow, and Kennedy Associ-          this was a costly endeavor, the practice was reserved
   ates. “death education,” in The Encyclopedia of Suicide.   for royalty and high-ranking members of the church.
   New York: Facts On File, 2003.                                Madame Tussaud of wax museum fame started
                                                              out making wax death masks of those killed by the
                                                              guillotine during the French Revolution. After
death investigation Whenever a death is not the               inheriting the wax figure collection of Phillipe Cur-
result of “natural” causes, the medical examiner or           tius, the doctor who had taught her, she moved to
coroner conducts an investigation to “seek out and            Britain with her collection and in 1835 opened her
speak the truth” about a given death. According to            museum in London.
John D. Howard, M.D., forensic pathologist and                   During the 1800s and early 1900s, interest in the
chief medical examiner of Pierce County, Wash-                new pseudoscience of phrenology (a now aban-
ington, the steps followed in a death investigation           doned study of the shape of the skull as indicative of
are: (1) gather a medical history of the deceased’s           different character traits and abilities) combined
prior health and activities and the history of the cir-       with more affordable casting materials, such as plas-
cumstances immediately surrounding death; (2)                 ter of paris, to increase the popularity of both life
gather information about the circumstances sur-               and death masks. By the 1930s, that popularity had
rounding the death from police, doctors, neighbors,           run its course.
etc.; (3) add the investigator or pathologist’s own
observations at the scene of injury, death, or place
of discovery of the body; (4) perform a physical              death penalty A judicial sentence of punishment
examination of the body; (5) use directed labora-             by execution.
tory and imaging studies such as X-rays, toxico-                 See also CAPITAL PUNISHMENT.
logic analyses, chemical analyses, and histologic
examinations.
                                                              death rate    The estimated number of deaths per
                                                              1,000 (usually) in a population occurring in a given
death knell A tolling of a bell, such as a church             area within a specified time. Also called a fatality rate
bell, announcing a death.                                     or crude death rate. Although only a rough indicator
                                                              of the mortality situation in a country for a one-year
                                                              period, a country’s death rate indicates the current
death mask       Cast made of the face following              mortality impact on population growth. The World
death. Death masks of one type or another have                Factbook (Washington, D.C.: Central Intelligence
been used since ancient times. The Egyptians fash-            Agency, 2002) gives estimated 2002 death rates per
ioned idealized death masks from thin gold plate              1,000 population for the following countries:
and other precious materials, and used them to pro-
tect the dead from demons in their afterlife. During
                                                              • Australia, 7.25 deaths
the Roman Empire, noble families displayed wax
effigies of their ancestors. Death masks were used             • Bahamas, 7.49 deaths
by Roman actors to play the part of the deceased.             • Canada, 7.54 deaths
   Death masks fashioned from the deceased’s actual           • Haiti, 14.88 deaths
face were first made out of wax in medieval Europe,
when it became customary to preserve the likeness             • Italy, 10.13 deaths
of great personages by making death masks. The                • Kuwait, 2.46 deaths
face, ears, and neck would be covered with oil, and           • Mexico, 4.99 deaths
then covered with liquid wax. Once the wax dried,
                                                              • Mozambique, 25.13 deaths
it would be carefully removed and used as a mold.
From the death mask molds, three-dimensional wax              • United Kingdom, 10.3 deaths
images were created to adorn tombs and crypts. As             • United States, 8.7 deaths
94 death rattle

According to the U.S. Census Bureau, the Planetary         • Seeing a hospital
Death Rate is:                                             • Seeing an ambulance
•   1.8 humans per second                                  Research suggests that as people live longer, with
•   106 humans per minute                                  death increasingly occurring more in the elderly
•   6,360 humans per hour                                  than in middle age or youth, along with advance
•   152,640 humans per day                                 warning from chronic diseases, death-related fears
                                                           have shifted from anxieties over postmortem judg-
•   55,713,600 humans per year
                                                           ment to fears of the dying process.

                                                           Doctor, Ronald M., and Ada P. Kahn. “death-related
death rattle     Noisy breathing in some patients
                                                              fears,” in The Encyclopedia of Phobias, Fears, and Anx-
who are near death. It occurs as the body’s respira-
                                                              ieties, Second Edition. New York: Facts On File,
tory and cardiovascular systems begin to fail, lead-
                                                              2000.
ing to a build-up of fluid in the lungs. As the breath
                                                           Lester, D., and A. Abdel-Khalek. “The Collett-Lester Fear
passes through this bronchial congestion, when the
                                                              of Death Scale: A Correction.” Death Studies 27, no. 1
normal cough reflex is lost, the breath comes out in
                                                              (January 2003): 81–85.
a rattle sound. If this breathing distresses the family,
the doctor may prescribe any of several medications
to dry the patient’s secretions and reduce the noise.
                                                           death row The cellblock or building in a prison
When this begins, it’s a sign that death will usually
                                                           where those condemned to death await execution.
occur within 24 to 48 hours. Death rattle is found in
                                                           Also called the death house.
about one dying patient in four.

Wildiers, H., and J. Menten. “Death Rattle: Prevalence,
                                                           death sentence      See CAPITAL PUNISHMENT.
   Prevention and Treatment.” Journal of Pain and Symp-
   tom Management 23 (2002): 310–317.
                                                           deathwatch     A vigil kept beside a dying or dead
                                                           person. Also, one who guards a condemned person
death-related fears    A fear hierarchy, or arrange-
                                                           before execution.
ment of fears relating to death, from maximum to
minimum, is sometimes used during therapy for an
individual who has a death phobia. The individual
                                                           deathwatch beetle        The common name for a bee-
may be asked to name the situation that arouses
                                                           tle family, Anobiidae, which makes a clicking or
maximum anxiety; that fear will be given a rating of
                                                           ticking sound as it burrows into wood. At one time,
100. The situation that causes the least anxiety is
                                                           the sound was superstitiously thought to fore-
given a five. A fear hierarchy or death-related fears
                                                           shadow the death of someone in the house where
for an individual might be:
                                                           it is heard. Literary critics have identified “the death
                                                           watches in the wall,” to which the narrator in Edgar
• Seeing a dead man in a coffin
                                                           Allan Poe’s “The Tell-Tale Heart” hearkened “night
• Being at a burial                                        after night,” as the deathwatch beetle.
• Seeing a burial assemblage from a distance
• Reading the obituary notice of a young person
  who died of a heart attack                               death wish A desire for self-destruction believed to
                                                           drive certain people to consistently put themselves
• Driving past a cemetery (the nearer, the worse)
                                                           into dangerous situations. A wish to die among the
• Reading the obituary notice of an old person             terminally ill may be an expression of depression,
• Being inside a hospital                                  suicidal intent, or coping. A 2002 German study of
                                                                                     dehydration benefits 95

an elderly population indicated that the wish to be        produce mummification, in which the body tissues
dead was mostly associated with the occurrence of a        dry and harden. Decay is about eight times faster in
major depression, self-rated higher depressivity,          the air than underground.
higher age, female gender, and negative life condi-            Obese individuals will decay faster, as will people
tions such as living in a nursing home.                    who died of bacterial disease or congestive heart
                                                           failure. Decomposition is delayed in deaths from
                                                           bleeding because blood provides a channel for the
death with dignity A natural death allowed to              spread of the putrefactive organisms within the
occur humanely with no attempt made to prolong             body. It tends to be more rapid in children than in
life by artificial means. The concept arose in reaction     adults, but slow in unfed newborn infants because
to the ability of modern medical technology to             of the lack of bacteria within their intestines. Heavy
maintain vital functions in, without improving the         clothing and other coverings will speed up putre-
condition of, persons who are at the point of death.       faction by retaining body heat. Injuries to the body
                                                           surface promote decomposition by providing portals
                                                           of entry for bacteria; plus, the associated blood pro-
decomposition      The breakdown of the body fol-          vides an excellent medium for bacterial growth.
lowing death. Without treatment, such as refriger-             After normal burial, the rate at which the body
ation or embalming, tissue decomposition begins            decomposes will depend to a large extent on the
immediately. Refrigeration is a necessity that pro-        depth of the grave, the warmth of the soil, the effi-
tects family and friends, the crematory operator,          ciency of the drainage, and the permeability of the
and the general public from potential health haz-          coffin. The restriction of air, in deep burials, partic-
ards. Neither embalming nor airtight and watertight        ularly in clay soil, will retard decomposition, but
caskets nor grave liners nor burial vaults prevent         never prevent it altogether. Buried in well-drained
decomposition of the body over a period of time.           soil, an adult body is reduced to a skeleton in about
   Within two days, microorganisms (bacteria,              10 years, and a child’s body in about five years.
enzymes, and fungi) that live in the intestines begin      Graveliners and other burial containers will slow
the process of decay by dissolving the internal            the process a bit, but will not prevent it.
organs. They produce gas, which bloats the body                An old rule of thumb says one week of decom-
before it eventually escapes. The face darkens and         position in air is equivalent to two weeks in water,
liquids escape the nose and mouth. The tongue              which is equivalent to eight weeks buried in soil,
swells and the abdomen begins to turn a greenish-          given the same environmental temperatures.
yellow color. Within one week, the flesh can become
liquid-like under the skin, and can fall off if touched.   Pounder, Derrick J. “Postmortem Changes and Time of
Eventually the skin blisters and fills with fluid or           Death.” University of Dundee. Available online. URL:
gas. After about a month, the body is extremely              http://www.dundee.ac.uk/forensicmedicine/llb/timed
decayed—hair and nails can be easily pulled out, the         eath.htm. Downloaded July 14, 2004.
trunk will be swollen to twice its size.
   If the weather is warm and humid, putrefaction
may set in within a day, but when left in a very cold      dehydration benefits It is natural for the dying
area or storage space, may be retarded for several         person to lose appetite and thirst, resulting in dehy-
months. Decomposition is optimal at temperatures           dration. Increasing evidence suggests that patients
ranging between 70 and 100 degrees Fahrenheit,             who are allowed to die without artificially supplied
and slowed below 50 degrees or above 100 degrees.          fluids die more comfortably than patients who
   Bodies found in a moist area may develop a              receive such treatment. Clinicians note that natural
waxy substance from the decomposition of body              dehydration results in metabolic changes that are
fat, known as adipocere. It makes the body float in         believed to produce a sedative effect on the brain
water and can preserve the internal organs. Heat           just before death, thus decreasing the need for pain
accelerates the decomposing, but very dry air may          medication. In addition, withholding or minimizing
96 delayed grief

hydration can have the desirable effect of reducing       worse than death were similar among all groups,
bronchial and oral secretions. Because there would        ranging from 18 to 31 percent. Patients were more
be less pulmonary congestion, coughing would              likely to accept life-sustaining treatment for states
diminish. Less fluid in the body results in less fre-      they considered better than death than for states
quent urination, and in turn, less risk of skin break-    they considered worse than death. More adult
down and bed sores. Less fluid in the body means           patients would refuse treatment if they had only
less pressure on tumors, and hence less pain for the      dementia with a terminal illness than if they had
patient.                                                  only dementia.
   See also ARTIFICIAL HYDRATION AND NUTRITION (AHN).
                                                          Kass-Bartelmes, Barbara L., and Ronda Hughes. “Advance
                                                             Care Planning: Preferences for Care at the End of Life.”
delayed grief    A type of abnormal grief that occurs        Department of Health and Human Services, Public
when grief reactions are inhibited, suppressed, or           Health Service Agency for Healthcare Research and Qual-
postponed for longer than two weeks. Also referred           ity. Available online. URL: http://www.nih.gov/ninr/
to as a form of complicated or unresolved grief. The         news-info/endria.pdf. Downloaded July 14, 2004.
bereaved may feel and exhibit little distress at the
time of his or her loss and continue calmly engaged
in everyday activities. After some time (days, weeks,     denial Denial, often accompanied by feelings of
or even years, in extreme examples), the grief reac-      isolation and loss, is the first stage people go through
tion is triggered, perhaps by another loss of a loved     upon learning they are dying, according to ELISABETH
one, or by something as apparently trivial as the         KÜBLER-ROSS. At least partial denial occurs in almost
loss of a personal object. At this juncture the full      all patients, Kübler-Ross believes—not only during
array of grief symptoms may emerge, although they         the early stages of illness or immediately following
may be organized around the more recent loss or           an explicit diagnosis, but also later on from time to
lost object, rather than the underlying, unresolved       time. She notes that denial functions as a buffer after
grief issue. Because adult children often must take       unexpected shocking news, allows the patient to
a responsible role following the death of a parent, it    collect him- or herself, and, with time, mobilize
is not uncommon for their own grief processes to be       other less radical defenses. Denial is temporary and
delayed.                                                  is replaced by partial acceptance. Kübler-Ross adds
                                                          that denial maintained until the end does not nec-
                                                          essarily bring increased distress, but that most
dementia Dementia is a chronic confusional state.         patients do not maintain it too long.
Although around 70 different conditions can cause             Denial is also a part of the grieving process for sur-
dementia in the middle and later years, Alzheimer’s       vivors. Cunningham writes that denial is especially an
disease is the most common, representing 60 per-          early stage of adolescent grief. “Teenagers, in particu-
cent of older persons who are irreversibly                lar, may show little signs of grieving in the begin-
demented. This progressive disorder is character-         ning. This numbness or form of denial is an important
ized by losses of memory, intellectual and language       coping mechanism and should be respected.”
ability, and general competency over a period aver-           Byrne echoes this advice: “Denial is usually tem-
aging six to 15 years and ending in death. AHRQ           porary and will be soon replaced by partial accept-
research shows that adults of various ages whose          ance. Denial is healthy because it serves as a ‘buffer’
current health states ranged from well to terminally      against shocking news, allowing individuals time to
ill differed in their perception of hypothetical health   collect themselves and form other defenses to the
states as being worse than death. For example, 66         news. A period of isolation may follow denial when
percent of younger well adults rated permanent            people refuse to accept what has happened.”
coma as being worse than death, compared to only              In another context, Kenneth Kramer, professor
28 percent of nursing home residents. However, the        of comparative religious studies at San Jose State
proportions of adults rating dementia as being            University in California, has been quoted as saying,
                                                                          diamonds from cremated remains 97

“We are in denial about death. Americans are                 with psychosocial support and counseling. Ongoing
extreme in their masking and disguising anything             pharmacotherapy is generally not beneficial and
that has to do with death. This is characteristic of         may even be harmful to patients who are grieving.
industrial cultures obsessed with material belong-           Evidence of disturbed self-esteem, hopelessness, an
ings. We feel we have a lot to lose.”                        active desire to die and ruminative thoughts about
                                                             death and suicide are indicative of depression in
Byrne, Beverly. “Grief and the Adolescent.” Texas A&M        patients who are dying.”
   University, July 3, 2002.                                    In the bereaved, depression may be a symptom
Cunningham, Linda. “Grief and the Adolescent.” TAG:          of COMPLICATED GRIEF REACTION, marked by a failure
   Teen Age Grief, Inc. Available online. URL: http://       to return to levels of performance or states of emo-
   www.thevine.net/~tag/grief.html. Downloaded March         tional well-being enjoyed prior to the loss. Casarett
   3, 2003.                                                  et al. explain the difference between depression and
Watstein, Sarah Barbara. “denial and terminal illness,” in   grief in the bereaved: “Physicians may find it diffi-
   The AIDS Dictionary. New York: Facts On File, 1998.       cult to distinguish grief from depression because
                                                             feelings of guilt, thoughts of death, and psychomo-
                                                             tor retardation can be features of both conditions.
depression A mental state characterized by a pes-            However, symptoms caused by depression typically
simistic sense of inadequacy and hopelessness, a             begin later, after one to two months of bereave-
despondent lack of activity and sluggish feeling;            ment, and persist for several months after the loss.
depression is common in both the dying and the               In addition, depression is the more likely diagnosis
bereaved. Depression is the fourth stage people go           when symptoms are constant. Prominent suicidal
through upon learning they are dying, according to           thoughts, profound changes in appetite or sleep, or
ELISABETH KÜBLER-ROSS. In studies, depression has            substantial decreases in function are also markers of
occurred in 50 percent of those patients without             depression. None of these criteria are absolute, but
impaired consciousness, increasing in their final two         they should prompt consideration of antidepressant
weeks of life.                                               therapy or referral to a psychiatrist.”
   Depression in the terminally ill may result from
a preexisting emotional disorder, loneliness (espe-          Casarett, David, Jean S. Kutner, and Janet Abrahm. “Life
cially among the elderly from multiple personal                 after Death: A Practical Approach to Grief and
losses), unbearable suffering, medication side-                 Bereavement.” Annals of Internal Medicine 134, no. 3
effects, or the illness itself. It can be treated with          (February 6, 2001): 208–215.
medication and psychotherapy. Selective-serotonin            Periyakoil, Vyjeyanthi S., and James Hallenbeck. “Identi-
reuptake inhibitors (SSRIs) are usually preferred               fying and Managing Preparatory Grief and Depression
for treatment of depression because they have a                 at the End of Life.” American Family Physician 65, no. 5
relatively rapid onset of action and fewer side                 (March 1, 2002): 883–890.
effects, compared with tricyclic antidepressants. An
SSRI acts by blocking the reuptake of serotonin so
that more serotonin is available to act on receptors         diamonds from cremated remains Among the
in the brain.                                                options available today for disposing of cremated
   Periyakoil and Hallenbeck explain that grief and          remains (CREMAINS), or in this case, utilizing those
depression present similarly in patients who are             cremains, is to have them fashioned into diamonds,
dying. “Conventional symptoms (e.g., frequent cry-           which can then be set in jewelry or other memorial
ing, weight loss, thoughts of death) used to assess          pieces. How is this possible? The body is made of
for depression in these patients may be imprecise            carbon. Diamonds are also made of carbon. So it is
because these symptoms are also present in                   not too surprising that enterprising individuals
preparatory grief and as a part of the normal dying          finally connected the dots and figured out how to
process. Preparatory grief is experienced by virtually       make synthetic diamonds from cremated remains—
all patients who are dying and can be facilitated            a Chicago company called LifeGem, with its first
98 direct burial

“diamonds” being completed in early 2003. Each              scattered in a favorite spot. Direct cremation usually
human body contains enough carbon to yield 50 to            costs less than the traditional, full-service funeral.
100 high-quality diamonds of varying sizes, from 1⁄4        Costs include the funeral home’s basic services fee, as
to 1 carat. The process takes 16 weeks, and after the       well as transportation and care of the body. A cre-
carbon is collected during the cremation, the               matory fee may be included or, if the funeral home
remaining ashes are returned to the family. Dia-            does not own the crematory, the fee may be added
monds produced by the company sell for $2,095 for           on. There also will be a charge for an urn or other
a quarter-carat gem up to $9,995 for three-quarter-         container. The cost of a cemetery plot or crypt is
carat diamonds, with discounts for multiple gems            included only if the remains are buried or entombed.
created from the same remains—or about the same             Funeral providers who offer direct cremations must
cost as a traditional funeral. More than 150 funeral        also offer to provide an alternative container that
homes in 27 states and Canada were already offer-           can be used in place of a casket.
ing the service during the company’s first year.
According to the company, it is possible to create a        Federal Trade Commission. “Funerals: A Consumer
diamond from previously cremated remains, but it               Guide.” Available online. URL: http://www.ftc.gov/bcp/
is much more difficult to collect the necessary car-            conline/pubs/services/funeral.htm. Downloaded July
bon. About half the company’s requests for infor-              14, 2004.
mation concern people’s pets.

                                                            dirge   A song or hymn of mourning composed or
direct burial     Also called immediate burial. The         performed as a memorial to a dead person. When
body is buried shortly after death, usually within          first used in English from its original Latin, the word
one day and in a simple container. No viewing or            was dirige and referred to the chanting or reading of
visitation is involved, so no embalming is necessary.       the Office of the Dead as part of a funeral mass. In
A memorial service may be held at the graveside or          Middle English, it was shortened to dirge and there-
later. Direct burial usually costs less than the tradi-     after took on a more general use for a mournful
tional, full-service funeral. Costs include the funeral     funeral hymn or lament.
home’s basic services fee (which includes taking
care of the paperwork), as well as transportation
and care of the body, the purchase of a casket or           disaster death A disaster is a condition or event of
burial container and a cemetery plot or crypt. If the       significant destruction, disruption, or distress to a
family chooses to be at the cemetery for the burial,        community. The highest natural disaster death toll
the funeral home often charges an additional fee for        in U.S. history was caused by the Galveston, Texas,
a graveside service.                                        hurricane of 1900, which killed an estimated 6,000
                                                            people. The most recent man-made disaster, the ter-
Federal Trade Commission. “Funerals: A Consumer
                                                            rorist attacks of September 11, 2001, resulted in
   Guide.” Available online. URL: http://www.ftc.gov/bcp/
                                                            about 3,000 deaths.
   conline/pubs/services/funeral.htm. Downloaded July
                                                               McKechnie writes that following disasters such
   14, 2004.
                                                            as these, families that have suffered loss may expe-
                                                            rience any of the following:
direct cremation The body is cremated shortly after
                                                            • Increased irritability, arguments and family dis-
death, without embalming. The cremated remains are
                                                              cord, including domestic violence
placed in an urn or other container. No viewing or vis-
itation is involved, although a memorial service may        • Clinging, acting out, and regressive behavior by
be held, with or without the cremated remains pres-           children
ent. The remains can be kept in the home, buried or         • Illness and psychosomatic problems for adults
placed in a crypt or niche in a cemetery, or buried or        and children
                                                                                                   donor quilts 99

• Exhaustion                                                   result, a person’s DNA can reveal much about her
• Decreased intimacy                                           genetic predisposition to many illnesses. Also,
                                                               because each person’s DNA is unique it is used to
• Increased alcohol consumption and/or substance
                                                               conclusively verify identity and heredity linkage.
  abuse
                                                               Scientists believe DNA research will provide even
• Survivor’s guilt                                             more information in the future that will enhance
                                                               and extend the quality of human life.
Communities that have been hit by disasters typi-                  Dr. Linda Randolph, medical services director of
cally perform rituals, set up shrines, or establish            GeneOptix, Inc., and president of Genetic Resources
other memorials in order to help the community as              Medical Group of Los Angeles: “The field of medical
a whole deal with the trauma and recover psycho-               research is rapidly discovering new disease and dis-
logically from the violence.                                   order links almost on a daily basis. DNA preservation
                                                               can provide families with a genetic autopsy capabil-
McKechnie, Heather. “After Disaster . . . Steps You Can Take   ity. Future testing will allow us to pinpoint the genes
  to Cope in Stressful Situations.” The Funeral Directory.     responsible for certain disorders and all for the pre-
  Available online. URL: http://www.thefuneraldirectory.       dictive testing of the children of the deceased.”
  com/afterdisaster.html. Downloaded July 3, 2003.                 As science discovers more and more information
                                                               about genes and how they work, documenting
                                                               one’s genetic makeup is becoming increasingly
discounted grief Lack of nominal or negligible                 important. Making this decision prior to cremation
social validation of a loss by others. Also known as           is critical; once cremation has taken place, DNA
marginalized grief. The Compassionate Friends                  retrieval is no longer an option. After a body is
explains that following the death of an adult child,           buried, it is very difficult, if not impossible, to
parents’ grief is often discounted. “If the adult child        retrieve enough DNA to obtain a complete DNA
dies as the result of an accident or an illness, parents       profile. Many funeral firms now offer a DNA
are often told (while being comforted by friends or            retrieval and storage program. Some diseases
family) that they should be grateful that their child          affected by this are: Alzheimer’s, asthma, cancer,
lived as long as he or she did.” The feeling of some           heart disease, muscular dystrophy, diabetes, blind-
is that because the parents had their child for 25, 30,        ness, multiple sclerosis, and cystic fibrosis. DNA
or 40 years, their grief is lessened. Discounted grief         Connections offers a list of DNA retrieval service
also occurs when the adult child dies from a cause             providers at http://www.dnaconnections.com.
that makes others uncomfortable or judgmental
regarding the cause of death.
    Discounted grief can also occur when someone               doctor-assisted suicide      See   PHYSICIAN-ASSISTED
loses a pet. The pet owner will be grieving, but others        SUICIDE.
may not consider a pet as “worthy” of such mourning.

The Compassionate Friends. “Death of an Adult Child.”          donor quilts      The American quilt has become an
  Available online. URL: http://www.compassionate              art form that captures the spirit and emotions of its
  friends.org/Brochures/adult_child.htm. Downloaded            creators, as well as a vehicle for interpreting our
  June 16, 2003.                                               connection between the past and present. In that
                                                               fashion, many support groups for bereaved families
                                                               of organ and tissue donors make remembrance
DNA retrieval and storage      DNA, formally known             quilts as a way for families to be involved in some-
as deoxyribonucleic acid, is found in most body cells          thing tangible concerning their loved ones and the
and is responsible for making up the gene markers              gift of life they chose to make. Following the death
that determine heredity. Presently more than                   and organ donation of a loved one, the donor’s
10,000 diseases have been linked to heredity. As a             family is invited to participate by making its own
100 do-not-resuscitate (DNR) orders

“memory square” or “patch.” Completed quilts are           example, one study found that patient preferences
then displayed at various support group meetings,          to decline cardiopulmonary resuscitation (CPR)
hospitals, health fairs, and community gatherings to       were not translated into DNR orders. CPR is a pro-
remind people that organ transplants depend on the         cedure frequently addressed in DNR orders. Another
generosity of donors. In the Wisconsin Donor Net-          study found that patients received life-sustaining
work’s quilt project, for example, families are            treatment at the same rate regardless of their desire
encouraged to share their feelings about making the        to limit treatment.
square and can include comments about the quilt               Related to DNR orders are Do Not Intubate (DNI)
square’s design. These are compiled into a booklet,        orders, which instruct that no breathing tube will be
which accompanies the quilt at public displays.            placed in the throat in the event of breathing diffi-
                                                           culty or respiratory arrest. Either DNR or DNI orders
                                                           may be given separately (a patient may have a DNR
do-not-resuscitate (DNR) orders            Instructions    order but not a DNI order or vice versa), but in most
from the patient, or the patient’s surrogate, to the       cases they are ordered together. Anyone setting up
physician not to resuscitate a patient who goes into       DNR/DNI orders needs to check with his or her state
cardiac or pulmonary arrest and appears to be near         regulations for guidance.
the cessation of vital functions. DNR is, in effect,
recognition of the futility of attempting to keep a        Agency for Healthcare Research and Quality. “Advance
person with terminal illness alive with advanced             Care Planning: Preferences for Care at the End of Life.”
life support systems. A specific DNR order on a              Department of Health and Human Services. Available
patient’s chart is part of the prescribed medical treat-     online. URL: http://www.ahrq.gov/research/endoflife/
ment plan and must have a physician’s signature. It          endria.htm. Posted March 2003.
is usually written for patients who are terminally ill,
suffering from an end-stage condition, or who are in
a persistent vegetative state. Such an order can be        Dover Air Force Base      Located in Delaware, Dover
made effective both within and outside a hospital          Air Force Base is the home of the Charles C. Carson
setting. DNR orders come under state law and can           Center for Mortuary Affairs, the military’s only state-
usually be revoked at any time either orally or in         side mortuary. The mortuary staff prepares the
writing, by physical destruction, by failure to pres-      remains of fallen U.S. soldiers, sailors, airmen, and
ent it, or by orally expressing a contrary intent by       marines as well as government officials and their
the patient or the patient’s health care surrogate. In     families stationed in Europe and Southwest Asia. Fol-
many states, physicians may issue the order. How-          lowing mass casualty events, specialists at the base
ever, a DNR order is always discussed with the             assist with the identification of the remains. Normal
patient, family, and doctor before it is formalized.       procedures include dental record checks, fingerprints,
DNR also acknowledges that “death with dignity”            and bone analysis. DNA samples can be taken and
may best be served in some people by not using             forwarded to other facilities for evaluation. Remains
extraordinary means to keep them alive.                    are inspected, identified, and prepared with the
    DNR implies that if a resuscitation attempt is         utmost dignity and respect as expeditiously as possi-
made, the patient could be revived. An order some-         ble for return to next-of-kin and final burial arrange-
what more precise than DNR, Do Not Attempt                 ments. The mortuary is the only one of its type in
Resuscitation (DNAR) indicates resuscitation efforts       the continental United States and the largest main-
should not be attempted regardless of expected out-        tained by the Department of Defense.
comes of those efforts.
    Agency for Healthcare Research and Quality
(AHRQ) research shows that care at the end of life         dowry death In most parts of India, the bride’s
sometimes appears to be inconsistent with patients’        family gives cash, jewelry, and household effects to
preferences to forgo life-sustaining treatment—and         the groom at the time of marriage. Thousands of
patients may receive care they do not want. For            brides are killed each year—most often burned alive
                                                                                        dying trajectory 101

in their kitchens—when their families refuse or are        While people with a terminal disease such as can-
late on dowry payments. The deaths may be caused        cer generally follow an expected course, or “trajec-
by the grooms but frequently are carried out by the     tory,” people with chronic diseases go through
grooms’ families.                                       periods of slowly declining health marked by sudden
   There were nearly 7,000 dowry deaths recorded        severe episodes of illness requiring hospitalization,
in India in 2001, the most recent statistics, accord-   from which the patient recovers. This pattern may
ing to Dr. Ranjana Kumari, director of the Center       repeat itself over and over, with the patient’s overall
for Social Research in New Delhi. But she adds that     health steadily declining, until the patient dies. For
for every case of dowry violence or murder regis-       these individuals there is considerable uncertainty
tered, an estimated 100 go unreported.                  about when death is likely to occur. Patients who
                                                        suffer from chronic conditions such as stroke,
Chandhoke, Deepali. “Dowry Death: Legal Redressal       dementia, or the frailty of old age go through a third
  against the Offense of Dowry Deaths.” Available       trajectory of dying, marked by a steady decline in
  online. URL: http://www.indianwomenonline.com/        mental and physical ability that finally results in
  womenhome/Serious/law/dowry/dowrybot.asp.             death. Patients are not often told that their chronic
  Downloaded July 5, 2003.                              disease is terminal, and estimating a time of death for
Duff-Brown, Beth. “Indian Woman Draws Attention to      people suffering from chronic conditions is much
  Dowries.” Associated Press, May 15, 2003.             more difficult than it is for those dying of cancer.
                                                           See also BODILY DETERIORATION AS DEATH
                                                        APPROACHES; DYING TRAJECTORY.
dressing of the corpse    Dressing the body is usu-
ally included in the funeral home’s basic services.     National Cancer Institute. “Loss, Grief, and Bereavement.”
Costs can be reduced by dressing the deceased in a         National Cancer Institute. Available online. URL:
favorite outfit instead of costly burial clothing. In       http://www.nci.nih.gov/cancerinfo/pdq/supportive-
the Sikh religion, the family usually prepares the         care/bereavement/patient. Updated July 9, 2003.
body for disposal themselves, bathing it and dress-
ing it in clean clothes.
   See also BURIAL CLOTHES.                             dying trajectory      Individuals who are dying do
                                                        not move toward death at the same rates or in the
                                                        same ways. Different causes of death are associated
durable power of attorney         Also known as a       with different patterns of dying. These patterns,
HEALTH CARE PROXY.     This document allows the         referred to as “dying trajectories,” indicate the path
patient to designate a surrogate, a person who will     of the individual’s dying experience. Attitudes and
make treatment decisions for the patient if he or she   behaviors of people caring for the patient are
becomes too incapacitated to make such decisions.       strongly influenced by the perception of the
                                                        patient’s dying trajectory. Trajectories will also affect
                                                        the types of emotional responses and coping mech-
dying declaration    See DEATHBED STATEMENT.            anisms patients and their families will display, as
                                                        well as the interventions that will be initiated. For
                                                        these reasons, the purpose of understanding one’s
dying process, the      The dying process can be        dying trajectory is to anticipate and implement
described in terms of duration and shape. Duration      appropriate interventions.
refers to the time involved between the onset of           Watstein describes the dying trajectory as “A
dying and the arrival of death. Shape designates the    graphic representation of the dying process. Time is
course of the dying process (i.e., whether one can      recorded along the horizontal axis and nearness to
predict how the process will advance, and whether       death along the vertical axis. The condition of a
the approximate timing of the death is expected or      dying individual is plotted across time, with the
unexpected).                                            resulting curve being the dying trajectory.”
102 dyspnea

   The following examples of trajectories have been      National Cancer Institute. “Loss, Grief, and Bereave-
described:                                                 ment.” Available online URL: http://www.nci.nih.gov/
                                                           cancerinfo/pdq/supportivecare/bereavement/patient.
• The “gradual slant” characterized by a long slow         Updated July 9, 2003.
  decline, sometimes over a period of years.             Watstein, Sarah Barbara. “Dying Trajectory,” in The AIDS
• The “downward slant” represented by a rapid              Dictionary. New York: Facts On File, 1998.
  decline toward death in which the chronic phase
  of the illness is either short or nonexistent.
                                                         dyspnea Difficult or labored breathing. An
• The “peaks and valleys” trajectory, in which there
                                                         uncomfortable awareness of such breathing is a
  are alternating patterns of remission and relapse.
                                                         common symptom at the end of life. For dying
• The “descending plateaus” trajectory, indicated        patients, dyspnea is one of the most feared and most
  by long, slow periods of decline followed by resta-    distressing symptoms. Caregivers with a calming
  bilization. Patients in this trajectory must repeat-   presence can help patients stay calm when they are
  edly adjust to different levels of functioning.        stressed by labored breathing.

Uncertain trajectories are more difficult to cope with
than certain trajectories, since ambiguity generates
anxiety and is often more difficult to cope with than
                                                                                 E
certainty.
   See also DYING PROCESS, THE.
                                                                                                              E
Education for Physicians on End-of-Life Care                       Believing that man will be resurrected after death
(EPEC) Supported by a grant from the Robert                    to live forever, death was merely a transitional stage
Wood Johnson Foundation, EPEC’s purpose is to                  along the way to a better life in the next world. The
train practicing physicians on the essential clinical          Egyptian Book of the Dead describes the travel of the
competencies required to provide quality end-of-life           soul into a next world without coming back to Earth.
care. The EPEC curriculum, developed by the Amer-              In order for the soul to function properly, the body
ican Medical Association, covers key competencies              must remain intact. When the body is in good con-
for all physicians who care for patients at the end of         dition after burying it, the soul returns to it again.
life. The course covers fundamental skills in pallia-          Because of the importance of keeping the body in
tive care, ethical decision making, symptom man-               good shape, along with the need to prepare for the
agement, communication, and psychosocial aspects               ensuing journey, the Egyptians embalmed and
of care at the end of life. Contact information:               mummified the dead, plus provided ample provi-
                                                               sions for the afterlife. This was seen as a continuation
The EPEC Project
                                                               of the existence before death. The Florida Interna-
Northwestern University School of Medicine
                                                               tional Museum describes the preparation:
 (NUMS)
750 North Lake Shore Drive
                                                                  When a person died, the priests recited prayers and
Suite 601
Chicago, IL 60611                                                 a final attempt was made to revive the deceased.
(877) 524–EPEC (toll-free)                                        The body was then washed and purified in a special
(312) 503–EPEC                                                    shelter called an ibu. The body was then taken to
(312) 503–4355 (fax)                                              the wabet, which was the embalmer’s workshop. A
info@epec.net                                                     cut was made in the left side, and all the organs
http://www.epec.net                                               were removed and stored in containers known as
                                                                  canopic jars. The body was then packed with a salt
                                                                  called natron for a period of forty days. After the
Egyptians, ancient     Some authors have described                forty days had passed, the insides were filled with
the ancient Egyptians as being obsessed with death,               linen or sawdust, resin and natron. The body was
but others say that is a misconception. According to              wrapped in bandages with jewelry and amulets
the Sheridan Libraries at Johns Hopkins University,               between the layers. A portrait mask was placed over
“In reality they were a people consumed by a pas-                 the head of the deceased by the Chief Embalmer,
sion for life. The Egyptians believed that their jour-            who wore a jackal mask to represent Anubis. The
ney through life and past death paralleled the                    wrapped body, or mummy, was put into a coffin
journey of the sun. Birth and death could be equated
to sunrise and sunset. Both the sun and the soul of            The mummification process took about 70 days,
the deceased needed to traverse the dangers of the             after which the body was placed in a decorated cof-
Underworld in order to be reborn again.” Herodotus,            fin and buried. The Egyptians were very careful to
the Greek historian, tells us the Egyptians were the           bury the dead a long way from water, laying the
first people to believe that the soul is immortal.              dead in tombs with the necessary food, drink, and

                                                         103
104 elegy

clothes to help the dead lead a happy life after res-           poses. Without treatment of embalming or refriger-
urrection. They believed that the size of the burial            ation, decomposition begins immediately.
chamber increased or decreased after interment,                     Embalming techniques evolved in two eras:
depending on the virtue of the deceased.                        ancient (begun by the Egyptians) and modern
    It was believed that once in the afterlife, the per-        (developed by Dr. Frederic Ruysch, who occupied
son would continue the occupations of this life, so             the chair of anatomy at Amsterdam, Holland, from
everything required was packed in the tomb along                1665 to 1717). The ancients, from Egyptians to Per-
with the body. Writing materials were often sup-                sians, Greeks, Peruvians, Aztecs, and early North
plied along with clothing, wigs, hairdressing sup-              American Indians, used various cleansing agents
plies, and assorted tools, depending on the                     and oils, such as wine, melted bitumen, sweet bal-
occupation of the deceased. Smaller models of occu-             sam, aloes, myrrh, or other spices; then wrapped
pational tools rather than full-sized ones would                the body in cloth or coated it in wax or salted it.
likely be placed in the tomb because models were                    According to the Museum of Funeral Customs
cheaper and took up less space. Once in the afterlife,          (Springfield, Illinois), the process of embalming that
the model tools would be magically transformed                  we know today dates to Europe in the 17th century;
into the real thing.                                            however, the technique did not come to America
    The Egyptians painted idealized scenes from daily           until 1840. “The process wasn’t used on a broader
life on the walls of their tombs: scenes of agricultural        scale until the time of the American Civil War in
work such as harvesting crops, tending cattle and               1861 when it became necessary to treat remains
fishing, scenes of artisans at their work, including             and prepare the dead for transportation to their dis-
gold workers and boat-builders, and domestic scenes             tant homes for burial. Abraham Lincoln’s body was
of banquets with musicians, dancers, and guests. The            embalmed, and his body was viewed by millions
scenes represented the hoped for afterlife, in which            over a twenty-day period in 1865. We believe that
there were fertile fields and harmony and happiness              the success of his embalming contributed to proving
at home; representing it in the tomb was thought to             the benefits and effects of the treatment. Embalm-
ensure an ideal existence in the next world.                    ing was used more widely in the late 1870s as a
    Food was provided for the deceased and should               means of allowing family members a longer period
the expected regular offerings of the descendants               of time before interment was necessary.”
cease, food depicted on the walls of the tomb would                 Canada and the United States are the only two
be magically transformed to supply the needs of the             nations that regularly practice embalming. Many
dead.                                                           funeral homes require embalming if you are plan-
                                                                ning a viewing or visitation. But embalming gener-
St. Petersburg Times. “Splendors of Ancient Egypt Educational   ally is not necessary or legally required if the body
    Guide.” Available online. URL: http://www2.sptimes.         is buried or cremated shortly after death. Eliminat-
    com/Egypt/Egypt.5.html. Downloaded July 5, 2003.            ing this service can save hundreds of dollars. Under
                                                                the Funeral Rule, a funeral provider:

elegy   A poem mourning someone or something                    • may not provide embalming services without
that has been lost; a lament for the dead.                        permission
                                                                • may not falsely state that embalming is required
                                                                  by law
embalm       To preserve a dead body from decay;
                                                                • must disclose in writing that embalming is not
although embalming only delays the decaying
                                                                  required by law, except in certain special cases
process, it does not stop it. The embalming process
replaces blood with preservative chemicals and also             • may not charge a fee for unauthorized embalm-
serves to disinfect the body of the deceased. This                ing unless embalming is required by state law
treatment allows the body to be displayed for sev-              • must disclose in writing that you usually have
eral days after death for viewing and funeral pur-                the right to choose a disposition, such as direct
                                                               employees’ needs as end-of-life caregivers 105

  cremation or immediate burial, that does not                airlines will accommodate religious objections if the
  require embalming if you do not want this service           casket is a sealed one.
• must disclose in writing that some funeral                     See also EGYPTIANS, ANCIENT; MUMMIFICATION.
  arrangements, such as a funeral with viewing,
  may make embalming a practical necessity and, if            Baris Funeral Home. “What Is Embalming & How Is It
  so, a required purchase                                        Done.” Available online. URL: http://www.baris.net/bfh/
                                                                 embalm.html. Downloaded July 14, 2004.
Embalming involves the following process, as
described by the Baris Funeral Home:
                                                              employees’ needs as end-of-life caregivers Caring
  To begin the embalming process, a small incision is         for terminally ill relatives, most of whom are elderly
  usually made on the remains right side of the lower         parents, is a new challenge for employees and a new
  neck. It is at this position that two of the largest cir-   reality for American business. In the 1980s, Ameri-
  culatory vessels are located; the carotid artery and        can businesses adapted their human resources poli-
  the jugular vein. Incisions are made in both vessels,       cies to accommodate the needs of workers with
  and a tube connected to the embalming fluid pump             young children. Now, many of those same workers
  is placed into the carotid artery. Another tube is          face a new responsibility: providing care for an older
  placed into the jugular vein; this is called a drain        parent, relative, or friend. Just as childcare did, the
  tube. The basic theory is to pump embalming fluid            growing need for eldercare presents employers with
  into the artery, which will cause the blood to return       workers who must juggle multiple demands on their
  through the veins and flow outside the remains for           time and energy. A 1989 survey of 3,658 employees
  disposal. Many fluids have a slight dye added to             in a major Southern California company revealed
  them, which gives the remains a pinkish glow, and           that 23 percent of their employees were providing
  also acts as a guide for the funeral director, making       eldercare. A similar study in 1990 for the National
  it visible for him to see the fluid as it travels through    Association of Area Agencies on Aging found that 32
  the remains. This type of embalming is known as             percent of their employees were caregivers. This is
  arterial embalming.                                         expected to increase in the future due to the growth
      The next step, called cavity embalming, is the          of older population, smaller family size; and an
  application of full strength fluid to the internal          increase in the two-earner households.
  organs of the remains. A small incision is made just           The stresses of caring for long-term, terminally ill
  above the navel, and a long needle called a trocar is       family members affect employee productivity. One
  placed inside the abdominal and thoracic cavities of        independent survey revealed that
  the remains. The funeral director aspirates both the
  abdominal and thoracic cavities. Aspiration is the          • 56 percent of respondents said they were less pro-
  removal of blood and other bodily fluids, through              ductive at work.
  suction. A suction pump, either water or electric
                                                              • 51 percent said they had to take time off during
  powered is used to remove these fluids. The trocar is
                                                                the work day for eldercare.
  then attached to a gravity fed system, which causes
  full strength fluid to be put into each organ, causing       • 30 percent reported being absent for a full day to
  a more thorough disinfection and preservation of              deal with eldercare matters.
  the remains All incisions are then sutured closed.          • one in four households are helping an elder.

Muslims do not allow embalming. Traditional Jew-              And in a survey done by the National Alliance for
ish beliefs also do not allow embalming but                   Caregiving in 1997, 10 percent of caregivers had to
reformed Jewish funerals do, especially if the body           give up work entirely.
is to be viewed at a wake.                                       The Centers for Medicare and Medicaid Services
    Shipping a body to another state may mean that            offers several suggestions for helping employees
the body will have to be embalmed, although most              who are end-of-life caregivers:
106 end-of-life care

• Provide employees with information about com-             available to help patients and their families with
  munity groups and caregiver organizations such            the medical, psychological, and spiritual issues sur-
  as area agencies on aging, hospitals, senior cen-         rounding dying. A HOSPICE often provides such
  ters, faith-based organizations, disease-specific         services.
  organizations, and local universities or commu-               The time at the end of life is different for each
  nity colleges or cooperative extension programs.          person. Each individual has unique needs for
• Raise awareness of the importance of advance              information and support. The patient and family’s
  directives, supplying information on how to               questions and concerns about the end of life should
  make decisions and offering assistance when               be discussed with the health care team as they
  employees face the death of a loved one.                  arise.
                                                                According to a report of a study by the Robert
• Offer flex-time, shortened work weeks, a modi-
                                                            Wood Johnson Foundation released in 1995, a need
  fied daily schedule, or telecommuting based on
                                                            exists for discussion and physician education in the
  need.
                                                            area of health care at the end of life. Persons near
• Provide supportive benefits such as dependent             death and their family members often experience
  life insurance, long-term care insurance cover-           extreme stress because of use or nonuse of medical
  ing spouse and parents/parents-in-law, flexible            procedures and lack of communication with their
  spending accounts/dependent care accounts,                health care practitioners.
  group legal/financial plans, cash subsidies for               Also in 1995 the American Medical Association
  services for older relatives, travel discounts for        established the Task Force on Quality of Care at the
  long-distance caregiving, hospice inclusion in            End of Life, “To aid physicians in identifying when
  company-sponsored health insurance, access to             in the care-giving process, a transition in care needs
  Employee Assistance Programs (EAPs) for coun-             may occur, and to identify actions that can be taken
  seling and support.                                       to improve the quality of life for those facing the
• Instill supportive policies such as paid sick leave       end of life.”
  that can be used for end-of-life care, paid family            In 2002 LAST ACTS, a coalition of nearly 1,000
  leave, leave without pay options, compressed work         organizations including the American Hospital
  options, job-sharing, employee leave-sharing,             Association, the American Medical Association, and
  gradual return to work policies, funeral and              the American Nurses Association, released a first-of-
  bereavement leave policies longer than three days.        its-kind national study that graded each state’s han-
                                                            dling of end-of-life care. The study examined legal
Centers for Medicare & Medicaid Services. “When Employ-     framework in states for making decisions about
  ees Become Caregivers: A Manager’s Workbook.”             one’s death, the number of deaths at home, the
  Available online. URL: http://cms.hhs.gov/partnerships/   extent and use of hospice programs—which the
  materials/caregiversresources/default/asp. Posted 2002.   coalition called the “gold standard” for end-of-life
                                                            care—pain management and control programs, and
                                                            training in end-of-life care.
end-of-life care     When a patient’s health care               No state did well in all the categories. Nearly all
team determines that a terminal disease, such as            the states had low grades in hospice care use,
cancer, can no longer be controlled, medical testing        specifically in the number of people over age 65
and treatment often stop. But the patient’s care con-       who used hospice care and the length of time in the
tinues. The care focuses on making the patient com-         program.
fortable. The patient receives medications and                  Among their recommendations for improving
treatments to control pain and other symptoms               end-of-life care, Stubbs and Pearson suggest:
such as shortness of breath, anxiety, depression, loss
of appetite, nausea, and constipation. Some patients        1. Families need more information about the dying
remain at home during this time, while others enter            process and access to realistic accounts of what
a hospital or other facility. Either way, services are         lay caregiving can entail.
                                                                                                entombment 107

2. Those who would support families dealing with               and more options in the treatment of medical con-
   the death of a loved one need to acknowledge                ditions, including the choice between treatments of
   two important characteristics of the caregiver’s            varying risks and benefits, the choice to undergo
   experience: first, caregivers are often shocked by           elective surgery, and the choice of non-treatment.
   their loved one’s deteriorating health, and sec-            Patients often overestimate the benefits and under-
   ond, the caregiver’s experience takes place                 estimate the risks of a treatment.
   within the context of intimacy.                                 The decisions that health care providers make
3. A more flexible timetable (than death expected               may be different than those of the patients and fam-
   in six months) should be built into the legislation         ily, suggesting the need for a mutual decision-making
   that regulates the hospice benefit—one that bet-             process. While some patients want to be actively
   ter reflects the uncertainty of this situation, and          involved in clinical decision-making, others prefer a
   helps a family begin the hospice process earlier.           passive role. Little is known about what patients
                                                               and their families view as important information to
4. The concepts of palliative care vs. acute care and          help them make a decision, or how best to inform
   their impact on the end of life need to be more             them about bad news and how to then proceed to
   fully understood by the public at large and                 discussion of treatment options.
   within the professional community.                              Some health care providers encourage advance
5. More in-patient hospice or palliative care beds             care planning to preserve the autonomy and
   within hospitals and/or nursing homes are needed.           wishes of the patient at the end of life. One of the
                                                               most difficult decisions to be made at the end of
Casteel, Chris. “Study Rates State on Palliative Care.” The    life is whether or not to discontinue life-sustaining
   Daily Oklahoman, November 19, 2002.                         treatment. Despite widespread support of advance
Kahn, Ada P. “end-of-life care,” in Stress A to Z. New York:   care planning, less than 20 percent of patients
   Facts On File, 1998.                                        complete an advance directive. The decision for
National Cancer Institute. “End-of-life care: Questions and    the discontinuation of treatment can result in con-
   Answers.” National Cancer Institute. Available online.      flict among patients, family members, and/or
   URL: http://cis.nci.nih.gov/fact/8_15.htm. Down-            health care professionals.
   loaded July 14, 2004.                                           Factors that can influence the patient’s decision-
Stubbs, Margaret, and Cynthia Pearson. “Family Care-           making process include the symptoms of pain,
   givers and the Dying: The Invisible Ordeal.” Presented      fatigue, and depression, and economic and social
   to the annual meeting of the National Women’s Stud-         factors, including the perception of burden.
   ies Association, Boston, Mass., June 14–18, 2000.

                                                               Endowment Care Fund       Money collected from
End-of-Life Choices       See HEMLOCK SOCIETY.                 cemetery property purchasers and placed in trust for
                                                               the maintenance and upkeep of the cemetery.

end-of-life decision making      Rapidly occurring
advancements in science and health care technol-               end-stage condition An irreversible condition
ogy are generating new decision-making issues for              that is caused by injury, disease, or illness, which
health care professionals, patients, and their fami-           has resulted in progressively severe and permanent
lies. Patients can now choose between treatments               deterioration, and for which, to a reasonable degree
with varying risks and benefits, choose to omit                of medical probability, treatment of the irreversible
treatment, and participate in advance care planning            condition would be ineffective.
for health care decisions.
    There is evidence that some patients want more
knowledge and want to be involved in the clinical              entombment      The ritual placing of a corpse in a
decision-making process. Patients are facing more              grave.
108 epitaph

epitaph    An inscription on a tombstone or monu-                 the possibility of using trusts for taxes as well as to
ment in memory of the person buried there. Also                   assure the safety and security of funds left to others
can refer to a short literary piece or summary state-             should be considered. Fifth, an attorney should be
ment to remember a deceased person.                               consulted to determine if joint ownership of prop-
                                                                  erty, like an automobile, home, or boat makes
                                                                  sense—generally it does, but not always. Sixth, an
equivocal death Post-suicide term concerning the                  executor should be named. Seventh, specific items,
“psychological autopsy.” An equivocal death is one                such as jewelry, antiques, and art works, should be
in which the cause is uncertain or unclear. The psy-              willed. If necessary, an inventory of specific bequests
chological autopsy procedure often makes possible                 to individuals or institutions should be drawn up.
a decision as to the cause of death. This usually                 Last, instructions for final matters—arrangement for
proves therapeutic for grieving survivors.                        the funeral, cremation or interment, or other impor-
                                                                  tant considerations—should be left.
Evans, Glen, Norman L. Farberow, and Kennedy Associ-
   ates. “Equivocal Deaths,” in The Encyclopedia of Suicide,   Roy, F. Hampton, and Charles Russell. “Estate Planning,”
   2nd ed. New York: Facts On File, 2003.                        in The Encyclopedia of Aging and the Elderly. New York:
                                                                 Facts On File, 1992.

estate planning A primary purpose of estate plan-
ning is to distribute your assets according to your            ethical dilemmas Health care professionals have
wishes after your death. Successful estate planning            an ethical obligation to protect life and to relieve
transfers your assets to your beneficiaries quickly             suffering. Autonomy, nonmalfeasance, benefi-
and usually with minimal tax consequences. The                 cence, and justice are accepted moral principles
process of estate planning includes inventorying               governing the behavior of health care professionals
your assets and making a will and/or establishing a            within society. Technological and medical advances
trust, often with an emphasis on minimizing taxes.             have created a conflict between the application of
Estate planning is not only for the wealthy. If your           these moral principles and certain kinds of medical
assets are worth $1 million or more, estate planning           treatment at the end of life, such as hydration and
may benefit your heirs. Even if your estate is not              tube feeding. The tension between which moral
likely to be subject to federal estate taxes, estate           principle takes precedence in which situation cre-
planning may be necessary to be sure your inten-               ates the conflict.
tions for disposition of your assets are carried out.
   Roy and Russell outline the basic elements of
estate planning:                                               ethics    A system or set of moral principles. Also,
                                                               the rules of conduct recognized in respect to a par-
   First, an attorney should be consulted when draw-           ticular class of human actions or governing a par-
   ing up a will, or to determine if an existing will          ticular group, culture, or profession, such as medical
   meets current federal and state law. Second, the            ethics. According to experts, 90 percent of the cases
   beneficiaries should be decided upon—spouse, chil-           that hospital ethics committees discuss deal with
   dren, relatives, charities, churches, colleges and          end-of-life issues.
   schools, museums, public art galleries, musical foun-          See also BIOETHICS.
   dations, etc. Third, the information needed for mak-
   ing a will should be organized: beneficiaries’ names
   and addresses, Social Security numbers, birth dates;        eulogy    A speech of praise given by a member of
   a list of assets and obligations should be compiled;        the family, clergy, a close personal friend, or a busi-
   property that is held jointly or individually should        ness associate of the deceased. The eulogy is not
   be specified; life insurance companies, policy types,        lengthy, but offers praise and commendation and
   and value of policies should be identified. Fourth,          reflects the life of the person who has died.
                                                                                                 euthanasia 109

euphemisms for death      Euphemisms are expres-         euthanasia      Also known as mercy killing. The word
sions that make difficult or emotional situations        “euthanasia,” as derived from its original Greek con-
more tolerable. They are used to soften the reality of   text, means an easy or painless death. It is used to
what is being communicated, sometimes by the use         refer to the hastening of a suffering person’s death.
of humor. Perhaps no “situation” has a longer list of    In recent years, two types of euthanasia are usually
euphemisms than death and dying. Among the               mentioned in professional discussions of termination
more common euphemisms for death are:                    of life. One is typed as “active” or direct or voluntary,
                                                         i.e., where life is ended by “direct” intervention,
   at rest                                               such as administering a lethal dose of a drug with
   bite the dust                                         the competent patient’s full, informed consent. The
   breathed her last                                     other is called “passive” or indirect, i.e., where death
   brought down the curtain                              results from withdrawal of life-support or life-sus-
   buy the farm                                          taining medications. Involuntary or nonvoluntary
   cashed in                                             active euthanasia involves a physician engaging in
   cash in your chips                                    an act to end a patient’s life without that patient’s
   checked out                                           full informed consent. Dr. Christiaan Barnard, who
   croaked                                               received international acclaim and recognition for
   curtains                                              pioneering work in heart transplant surgery, wrote
   deceased                                              in Good Life, Good Death: A Doctor’s Case for Euthana-
   departed this life                                    sia and Suicide that: “Indeed, even though many doc-
   ended his days                                        tors will not admit it, passive euthanasia is accepted
   end of the line                                       medical practice—a common occurrence in wards
   expire                                                where patients live out their final hours.”
   give up the ghost                                         Evans and Farberow explain further:
   gone
                                                            Most people’s notion of euthanasia is best described
   go to heaven
                                                            by the term “mercy killing,” or active intervention
   go to one’s just reward
                                                            to end life. The layman is often uninformed about
   go to the happy hunting ground
                                                            the concept of passive euthanasia. So-called mercy
   go to the last roundup
                                                            killings rose 10 times in the 1980s, say co-authors
   heard the trumpet call
                                                            Derek Humphry and Ann Wickett in The Right to
   his number’s up
                                                            Die: Understanding Euthanasia. This, compared to
   kick the bucket
                                                            any five-year period since 1920. The authors, hus-
   laid to rest
                                                            band and wife, are co-founders of the Hemlock
   left the building                                        Society in Los Angeles, California. Humphry and
   left us                                                  Wickett’s book, Jean’s Way, is Humphry’s account of
   meet one’s maker                                         helping his critically ill first wife take her own life.
   meet the Grim Reaper                                     Humphry also published the first U.S. guide to “self-
   on one’s last legs                                       deliverance,” Let Me Die Before I Wake, in 1981; it was
   passed on                                                revised in 1984 and 1987 but is now out of print.
   pay the piper                                                In 1935, the British Voluntary Euthanasia Soci-
   pushing up daisies                                       ety was formed, followed by the founding in 1938
   ran out of time                                          of the Euthanasia Society of America. In 1980, the
   returned to dust                                         World Federation of Right-to-Die Societies was
   singing with the angels                                  founded, with 27 groups from 18 countries joining.
   six feet under
   sleep with the fishes                                 The question of whether a physician should assist
   walked the plank                                      patients with an intolerable terminal condition to
110 execution

end their life has been debated since the practice of   A Dutch study reported in the July 26, 2003, issue
medicine began with Hippocrates. The debate sur-        of the British Medical Journal found that death by
rounding PHYSICIAN-ASSISTED SUICIDE and voluntary       euthanasia may cause less grief for family and
euthanasia still rages.                                 friends than a natural death does. The researchers
   Essinger notes that American society appears to      proposed as possible reasons: they had time to pre-
be ready for the legalization of physician-assisted     pare and talk about the death, and they had the
suicide and euthanasia. “A 1991 General Social          chance to say goodbye to their loved one. Euthana-
Survey conducted by the National Opinion                sia is legal in the Netherlands, where about 3,000
Research Center asked the following question:           people choose to die by that method every year—
When a person has an illness or disease that cannot     about 80 percent of whom have cancer.
be cured or is in a permanent vegetative state,             The researchers noted that there were important
do you think doctors should be allowed by law to        demographic differences between the families choos-
end the patient’s life by some painless means if        ing euthanasia and those where their loved ones died
the patient and his or her family request such          of natural causes. Friends and family members of the
measures? More than 70 percent of those queried         euthanasia patients averaged more education, were
responded ‘yes.’ A Gallup poll in 1994 indicated        less religious, and were made up of more cousins, in-
that 65 percent of the U.S. public is in favor of       laws, and friends. The death by natural causes group
allowing doctors to help the terminally ill end their   contained more children and siblings.
suffering. In a Harris poll conducted in 1999, 73
percent of respondents agreed that physicians           Essinger, Douglas. “Attitudes of Tennessee Physicians
should, without penalty, be allowed to assist the          toward Euthanasia and Assisted Death.” Southern Med-
terminally ill with their death.”                          ical Journal 96, no. 5 (2003): 427–435.
   But physicians are more polarized in the debate,     Evans, Glen, Norman L. Farberow, and Kennedy Associ-
largely because of the Hippocratic Oath they have          ates. “Euthanasia,” in The Encyclopedia of Suicide, Second
taken, which states, “I will neither give a deadly         Edition. New York: Facts On File, 2003.
drug to anybody if asked for it, nor will I make a      Humphry, Derek, and Ann Wickett. The Right to Die: Under-
suggestion to this effect.” Strong religious beliefs       standing Euthanasia. New York: HarperCollins, reprint,
can also affect their arguments. Essinger, who sur-        July 1987.
veyed a random sampling of more than 1,100 Ten-
nessee physicians, comparing results to other states,
explains the challenge of legalizing euthanasia:        execution      Putting a condemned person to death.
                                                        It is also used to describe unlawful premeditated
  The Tennessee study, performed in the “buckle of      killing of a human being, such as in gangland or
  the Bible Belt,” is a replication of the Washington   Mafia executions.
  study in the Northwest and the South Carolina             Hanging was the predominant method of execu-
  study in the South, thus representing three geo-      tion in this country until quite recently, having been
  graphic regions of the country. When physicians       brought to America from England by the early set-
  were asked whether a situation might arise in         tlers. In 1967 two sociologists estimated that some
  which they themselves would administer a lethal       16,000 people had been executed by hanging in
  overdose, only 25 percent of Tennessee physicians     America. It was inexpensive and easily carried out.
  responded that they would participate in euthana-     However, it could also be very painful, requiring up
  sia (58 percent in Washington and 29 percent in       to twenty minutes for a prisoner to strangle to death.
  South Carolina). If the polarized attitudes of        Some were decapitated. In the late 19th century, the
  physicians in these states are near exemplary of      “long drop” was introduced. This method of hanging
  those among physicians in other states, it will       uses a formula that determines the length of the
  be difficult at best to formulate and implement       rope to be used based on the weight of the prisoner.
  laws and policies concerning assisted death and       The fall is made long enough to break the prisoner’s
  euthanasia.                                           neck so that he will die almost immediately.
                                                                                                   executor 111

    Despite improvements in the method, hanging             Brooks would become the first person executed by
fell out of favor in most jurisdictions. Many bungled       lethal injection in Texas on December 2, 1982.
executions were reported and hanging became asso-           Today, 37 of the 38 states that have the death
ciated with illegal lynchings. Also, the centralization     penalty use this method of execution.
of capital punishment facilitated the use of such               When lethal injection is used, sodium thiopental,
methods as electrocution and lethal gas that were           an anesthetic that puts the inmate to sleep, is
not feasible at the local level. Two states, New            injected first. Next flows pavulon or pancuronium
Hampshire and Washington, currently provide for             bromide, which paralyzes the entire muscle system
hanging as an option. Since 1976, three inmates             and stops the inmate’s breathing. Finally, the flow of
have been executed by hanging: two in Washing-              potassium chloride stops the heart. Death results
ton, and the last, in 1996, in Delaware.                    from anesthetic overdose and respiratory and car-
    In 1888 New York became the first state to adopt         diac arrest, while the condemned person is uncon-
electrocution as its method of execution. William           scious. One potential problem with lethal injection
Kemmler was the first man executed by electrocu-             is that medical ethics preclude doctors from partic-
tion in 1890. Eventually, 26 states adopted electro-        ipating in executions. Thus, the injections are often
cution as a “clean, efficient and humane” means of           performed by inexperienced technicians or order-
execution. Today, only Nebraska requires electro-           lies. According to the Death Penalty Information
cution; nine others offer it as an option. It is the sec-   Center, “If a member of the execution team injects
ond most common method of execution utilized in             the drugs into a muscle instead of a vein, or if the
the modern era (since 1976).                                needle becomes clogged, extreme pain can result.
    Utah has provided for death by firing squad since        Many prisoners have damaged veins resulting from
territorial days in 1854 (along with hanging and            intravenous drug use, and it is sometimes difficult to
beheading). Nevada also gave inmates the choice of          find a usable vein, resulting in long delays while the
the firing squad or hanging beginning in 1911. Only          inmate remains strapped to the gurney.” Contact
one inmate was ever executed by shooting in                 information:
Nevada (in 1913 by an “execution machine” con-
                                                            Death Penalty Information Center
sisting of three pre-aimed rifles) before the state
                                                            1320 18th Street NW
switched to lethal gas. Shooting was also the penalty
                                                            5th Floor
imposed by the military for deserters in time of war,
                                                            Washington, DC 20036
but has been used only once since the Civil War
                                                            http://www.deathpenaltyinfo.org
(Private Eddie Slovik, 1945). Three states (Utah,
Idaho, and Oklahoma) provide for execution by fir-              See also CAPITAL PUNISHMENT.
ing squad today. Since 1976, there have been only
two executions by firing squad, both in Utah, the            Florida Corrections Commission. “Executions in the U.S.—
last in 1996.                                                  A Brief History.” Available online. URL: http://www.
    Nevada was the first state to adopt lethal gas in           fcc.state.fl.us/fcc/reports/methods/emushist.html.
1921; it was seen as an improvement over hanging,              Downloaded July 14, 2003.
firing squad, and electrocution because it was less
violent and did not disfigure or mutilate the body.
Eleven states adopted lethal gas, including three           executor The person responsible for settling the
that had previously used electrocution. Five states         estate of a person who has died. In addition to filing
currently have statutes providing for lethal gas,           the deceased’s will with the probate court, the
although none retain it as their only method.               executor must see to it that all taxes and any claims
Eleven inmates have been executed by lethal gas in          against the estate are paid; following which, he or
the modern era (since 1976).                                she distributes any assets to the beneficiaries. Any
    In 1977, Oklahoma became the first state to             U.S. citizen over the age of 18 who hasn’t been con-
adopt lethal injection as a means of execution,             victed of a felony can be named the executor of a
although it would be five more years until Charles           will. Some people choose a lawyer, accountant, or
112 exhumation

financial consultant because of his or her expertise.            Metlife Consumer Education Center. “Being an Executor.”
Others choose to appoint a spouse, adult child, rel-              Available online. URL: http://www.pueblo.gsa.gov/
ative, or friend, especially if the estate is small. Gen-         cic_text/money/executor/executor.htm. Downloaded
erally, a family member or friend expects little or no            July 14, 2003.
pay for settling the estate and is anxious to get
things settled quickly and smoothly.
                                                                exhumation      Digging up a corpse that has been
Hughes, Theodore E., and David Klein. The Executor’s            buried.
  Handbook: A Step-By-Step Guide to Settling an Estate for
  Personal Representatives, Administrators, and Beneficiaries,
  Second Edition. New York: Facts On File, 2001.
                                                                                                                 F
failure to thrive     Vague terminology borrowed                    fear of death or dying     See THANATOPHOBIA.
from pediatrics to describe a clinical syndrome in
the elderly indicated by a gradual decline in physi-
cal and/or cognitive function. Other terms com-                     feast of the dead   A ceremony held in certain cul-
monly used are “wasting away” and “sundown                          tures to honor departed ancestors. For example, the
syndrome.” Its most common symptoms include                         Japanese feast of the dead is called obon season, at
weight loss, decreased appetite, malnutrition, and                  which time filial duty is fulfilled by welcoming the
inactivity, often accompanied by dehydration,                       spirits of one’s ancestors for an annual return in
depression, dementia, impaired immune function,                     which their souls are “fed,” then setting them free
and low serum cholesterol. Failure to thrive occurs                 at the end of the season in the Floating Lanterns
in both acute and chronic forms, leading to                         Festival. Another example: During Samhain, the
impaired functional status, morbidity from infec-                   Celtic connection to our Halloween and a feast of
tion, pressure sores, and increased mortality.                      the dead, it was believed the dead could, if they
   Failure to thrive has been defined as “an unex-                   wished, return to the land of the living for this one
plained decrease in function, structure or metabolic                night, to celebrate with their family, tribe, or clan.
process occurring in excess of that expected for age.”                 See also DAY OF THE DEAD.
But even that is not accepted by everyone.
Roubenoff and Harris note, “At this time, there are
no commonly accepted definitions for either the                     fetal death Technically, the loss of a fetus at any
‘failure to thrive’ syndrome or for the newly                       stage is a fetal death. However, in an attempt to
described syndrome of sarcopenia (loss of muscle                    separate spontaneous abortion from later pregnancy
mass or strength). This lack of a common definition                  loss, both the World Health Organization and the
makes it difficult to contrast study results and under-              American College of Obstetricians and Gynecolo-
stand the etiology of these syndromes.”                             gists (ACOG) recommend that statistics for fetal
   With early intervention to prevent further pro-                  death include only deaths occurring in utero in
gression, failure to thrive can be managed by pri-                  which the fetus weighs 500 g (1.1 pounds) or more.
mary care physicians and health care providers such                 ACOG also recommends including deaths occurring
as social workers and dietitians. Untreated, it can                 at 22 weeks’ gestation or after (other groups use
lead to premature death.                                            gestation of 20 weeks). Although this definition of
                                                                    fetal death is the one used most frequently in the
Roubenoff, R., and T. B. Harris. “Failure to Thrive, Sacro-         medical literature, it is by no means the only defi-
   penia and Functional Decline in the Elderly.” Clinics in         nition in use, even in the United States.
   Geriatric Medicine 13, no. 4 (November 1997):                       The National Center for Health Statistics, a part of
   613–622.                                                         the Centers for Disease Control and Prevention,
Verdery, R. B. “Failure to Thrive in Older People.” The             periodically updates the Model State Vital Statistics
   Journal of Nutrition, Health & Aging 2, no. 2 (1998):            Act and Regulations to assist states in developing
   69–72.                                                           vital statistics laws. They recommend reporting fetal


                                                              113
114 final details

deaths that occur in fetuses weighing 350 g or more       those who must handle the myriad of final details
or in fetuses at 20 weeks’ gestation or older. This       during the first few months following a death. Their
policy is not followed uniformly, and substantial         guide is available at no cost from:
differences exist between states. In addition, not all
                                                          AARP
states interpret the number of weeks of gestation in
                                                          Grief and Loss Program
the same manner.
                                                          601 E Street NW
   In 1997 the fetal death rate in the United States
                                                          Washington, DC 20049
was 5.8 deaths per 1,000 births. This rate has been
                                                          http://www.aarp.org/griefandloss/articles/70_a.html
steadily decreasing during the past 50 years. World-
wide, the fetal death rate varies considerably,              Basically, it suggests and goes into detail about
depending on the quality of available medical care.       the following steps:
In the United States, the fetal death rate is higher in
Hispanic and African-American populations than in         Step 1. Collect the necessary papers Before you
other populations. The rate also is higher in women          can file for various benefits and take care of other
older than 35 years and continues to increase with           financial matters, you will need to collect a vari-
advancing age. This group is at increased risk               ety of documents.
because of the higher incidence of medical prob-          Step 2. Contact insurance companies In addition
lems in the mother and because of the higher risk of         to life insurance, check to see if other forms of
genetic abnormalities in the fetus.                          insurance covered the deceased. Some loans,
   Motor vehicle accidents are a serious threat to           mortgages, and credit card accounts are covered
developing fetuses. Each year more fetuses than              by credit life insurance, which pays off account
infants die from motor vehicle accidents, according          balances. Contact each insurance company about
to a report from the University of Pittsburgh’s Cen-         how to claim the policy benefits.
ter for Injury Research and Control, which looked at      Step 3. Notify Social Security You will need to
the nearly 15,000 fetal death certificates from 16            notify the Social Security Administration if the
states from 1995 to 1997. Any fetus over 20 weeks            deceased was already receiving Social Security.
of gestation that died either from direct trauma or          When applying for survivor’s benefits, you will
maternal trauma was included in the study. Of the            need to have birth, death, and marriage certifi-
240 traumatic fetal deaths, 82 percent were due to           cates, Social Security numbers, and a copy of the
motor vehicle accidents. Once adjusted for the rest          deceased’s most recent federal income tax return.
of the country, the researchers estimate there are        Step 4. Claim benefits Veterans, Social Security,
more than 370 motor vehicle-related fetal deaths             and employee benefits may be available to you.
per year. This compares to an average 180 motor              Unions and other professional organizations pro-
vehicle-related infant deaths per year.                      vide benefits as well.
                                                          Step 5. Begin probate Probate is the court-supervised
“Fetal Deaths.” The Medical Herald, March 2002.              process of paying the deceased’s debts and dis-
Lindsay, James L. “Evaluation of Fetal Death.” eMedi-        tributing the estate to the rightful beneficiaries.
   cine Textbooks. Available online. URL: http://            Jointly owned property, property in trust, and
   www.emedicine.com/med/topic3235.htm. Updated              assets with a designated beneficiary (life insur-
   May 14, 2002.                                             ance, 401[k], pensions) do not go through the
                                                             probate process. If the deceased did not have a
                                                             will, state law will determine how the deceased’s
final details Immediately following the death of a            assets and property will be distributed to family
family member, the grieving family must attend to            members. The court will appoint a personal rep-
what is euphemistically called the “final details”—           resentative or the person named in the will as
perhaps to soften the more crass “financial arrange-          executor to manage the deceased’s affairs. Con-
ments.” The American Association of Retired                  tact the probate court in the state where the
Persons (AARP) has prepared a booklet to guide               deceased lived for details.
                                                                                                     flowers 115

financing end-of-life care       Financing end-of-life   is to develop an innovative financing model that
care has become a complex and increasingly impor-       captures the Medicare and Medicaid reimburse-
tant issue for state and federal governments, largely   ments for dual-eligibles and to supplement that
due to the recent shift in age demographics. In their   financing model with private funding. Such financ-
report, sponsored by the Robert Wood Foundation,        ing could come from commercial payers or individ-
Austin and Fleisher note: “As the number of indi-       ual out-of-pocket reimbursements to create a single
viduals in need of end-of-life care grows with each     pool of dollars for a broad-based end-of-life care
passing year, the challenge of providing that care      program.”
will become more difficult. The health care system,
especially those sectors devoted to end-of-life care,   Austin, Bonnie J., and Lisa K. Fleisher. Financing End-of-Life
will face increasing economic and labor-force             Care: Challenges for an Aging Population. AcademyHealth.
stresses in coming decades as a result of elderly         Available online. URL: http://www.hcfo.net/pdf/
Americans living longer than they have in the past.       eolcare.pdf. Posted February 2003.
The Medicare and Medicaid programs will bear the
brunt of this strain.” Currently the following sys-
tems pay for end-of-life care in the United States:     Five Wishes at Work       A low-cost and easy-to-use
                                                        legal document that helps employees and their fam-
Medicare Medicare is the largest funding source         ilies plan for difficult elder-care and end-of-life
   for end-of-life care, serving more than 80 per-      issues. Developed by the nonprofit organization
   cent of people who die in the United States each     Aging with Dignity, Five Wishes addresses physical,
   year. Approximately one-quarter of Medicare’s        emotional, and spiritual needs of the seriously ill
   annual budget is spent on its beneficiaries’ last     and dying. Designed for use in workplaces large or
   year of life.                                        small, the program consists of a LIVING WILL, which
Medicaid Approximately 20 percent of Medicare           enables people to express their preferences for the
   decedents are also Medicaid beneficiaries. Med-       person to make care decisions for them, medical
   icaid expenditures for hospice care vary dramat-     treatment they do or do not want, how they want
   ically among states.                                 people to treat them, and what they want their loved
Private Sector Private sector payers offer a            ones to know. A DURABLE POWER OF ATTORNEY for
   wide range of end-of-life benefits and funding       health care allows people to choose someone to
   mechanisms, which vary from state to state—          make decisions if they become unable to do so.
   often even within one commercial insurance           Employers offering the benefit receive sample e-mail
   company.                                             messages, newsletter articles, and flyers to help
Informal Caregivers A significant amount of             announce the program. The cost for companies to
   health care for the dying is paid out of people’s    offer Five Wishes is $1 per person. Five Wishes meets
   pockets. Some informal caregivers leave their        the legal requirements of 35 states and the District of
   jobs to provide care to terminally ill family mem-   Columbia. Information is available from:
   bers, which can be financially devastating.
                                                        Aging with Dignity
The report’s authors explain that because the cur-      P.O. Box 1661
rent payment system is siloed (multiple depart-         Tallahassee FL 32302
ments, and sections within departments, running         (850) 681–2010
different programs, have different and competing—       (850) 681–2481 (fax)
although often duplicated— information and paper-       http://www.agingwithdignity.org
work requirements), it does not promote a
continuum of care at the end of life, but integrating
funding sources may offer one solution to the chal-     flowers Flowers have a long association with
lenge of providing comprehensive, cost-efficient,       death and funerals. Floral offerings were originally
high-quality care. “The challenge for policymakers      intended to gain favor with the spirit of the
116 forensic anthropology

deceased. Archaeologists have found shallow graves        to 40 percent, and it has, according to trade sources,
dug by hand or crude tools, with flowers carefully         gone down steadily since then. By 1995 sales had
placed on the body of the deceased.                       further declined to 14 percent of what was now a
   Thera writes, “According to Buddhism, flower-           $14 billion industry. While the floral industry has
wreaths are essential in order to show the imper-         no statistics on how many flower shops are owned
manence of life. Just as the beautiful flowers decay       by undertakers, one can assume that the “arrange-
and fade away, so life too is shown to decay and          ment” (or a markup) continues to be a sideline
fade away. When flowers decay no one likes them.           source of income for the mortuary.
They are thrown away. Similarly after death no one
likes the decaying body. This understanding comes      All Funeral Flowers. “Funeral Etiquette.” Available
when one sees flower-wreaths at a funeral. If             online. URL: http://www.allfuneralflowers.com/funeral
flower-wreaths are absent at a funeral, that under-        etiquette.php. Downloaded July 18, 2003.
standing hardly occurs.”                               Thera, Ven. D. Mahinda. “Buddhist Points Misunderstood.”
   Sending a floral tribute continues to be an appro-      Metta Net-Lanka. Available online. URL: http://www.
priate way of expressing sympathy to the family of        metta.lk/english/buddhist-points.htm. Downloaded
the deceased. Flowers express a feeling of life and       July 19, 2003.
beauty and offer much comfort to the family.
Funeral floral etiquette dictates that:
                                                       forensic anthropology      The application of the sci-
• Floral baskets or living plants are appropriate      ence of physical anthropology to the legal process.
  when the sender had a closer relationship to the     The identification of skeletal, badly decomposed, or
  bereaved than to the deceased; usually sent to       otherwise unidentified human remains is important
  the bereaved’s home or workplace.                    for both legal and humanitarian reasons. Forensic
• Sympathy baskets, sent to the funeral home or        anthropologists identify human remains and assist in
  the bereaved’s home, are appropriate when sent       the detection of crime. Forensic anthropologists fre-
  by family or by those who had a deeper or formal     quently work in conjunction with FORENSIC PATHOL-
                                                       OGIST, odontologists (forensic dentists), and homicide
  relationship with the deceased.
                                                       investigators to identify bodily remains and discover
• Floral wreaths, crosses, and sprays are appropri-    evidence of foul play and/or the time lines of death,
  ate when sent by anyone acquainted with the          burial, and so on. In addition to assisting in locating
  deceased. The exception to this would be associ-     and recovering suspicious remains, forensic anthro-
  ations that would like to honor the deceased for     pologists work to suggest the age, sex, ancestry,
  service during his lifetime.                         stature, and unique features of a decedent from the
• Lid arrangements and casket covers are tradi-        skeleton. Age can be determined by examining the
  tionally reserved for family members.                wear to joints and other body parts. Gender can be
                                                       determined through the pelvis bone and skull.
That said, the use of flowers at funerals appears to    Forensic anthropologists help identify individuals
be declining as more and more families request that    who died in mass disasters, wars, or due to homicide,
donations to specified nonprofit organizations or      suicide, or accidental death.
religious funds be made “in lieu of” flowers. In The
American Way of Death Revisited (1998), Jessica Mit-
ford writes:                                           forensic pathologist     The application of analytical
                                                       methods, including the AUTOPSY, in order to discover
  Funeral flowers accounted for 65 to 70 percent of     the cause and manner of death of a deceased person
  the cut-flower industry’s revenue in 1960, and       so that proper legal action can be taken. Not all doc-
  many funeral homes either had an ownership           tors who perform autopsies are forensic patholo-
  interest or a commission “arrangement” with the      gists; however, in complex cases, forensic
  local florist. By 1970 the market share had dropped   pathologists are usually consulted.
                                                                            fraud in the funeral industry 117

forensic toxicology Evaluation of various bodily            At least $20 billion is currently invested in pre-need
fluids for the purpose of discovering whether a per-         funeral and cemetery plans, with no way of telling
son was under the influence of any drug at the time          how much of it is invested safely. Cemeteries are
of death.                                                   among the most loosely regulated of public entities.
                                                            Badly managed or fraudulent pre-need programs
                                                            are bilking tens of thousands of older citizens out of
Foundation of Thanatology The Foundation of                 millions of dollars, but the Federal Trade Commis-
Thanatology was established by Dr. Austin H.                sion’s (FTC’s) FUNERAL RULE—the only federal law
Kutscher in 1967 to stimulate and organize educa-           covering the industry—does not monitor pre-need
tional, scientific, and humanistic inquiries into the        funding or direct sales from cemeteries. While the
psychological aspects of: dying, reactions to death,        vast majority of death-care firms are handling pre-
loss, and grief; and recovery from bereavement.             need funds honestly, at least $50 million in pre-
Contact information:                                        need funds have been stolen or reported missing
                                                            nationwide. Although many states are improving
Foundation of Thanatology                                   their laws, the key weakness of most of the new
Columbia-Presbyterian Medical Center                        legislation is that little funding is being set aside for
630 West 168th Street                                       auditing and enforcement to stop future theft.
New York, NY 10032
(718) 601–4453                                           Among the instances of funeral home fraud that
(718) 549–7219 (fax)                                     Horn documents in her exposé are exorbitant
http://www.lifethreat.org                                markups of caskets, hearses, flowers, and vaults;
                                                         bribing clergy in exchange for a recommendation
                                                         from the pulpit; and sending gifts to nurses who
fraud in the funeral industry Any industry will          alert them to dying patients so they can step in
have its periodic thieves and charlatans, and the        immediately and lead the grieving family to think
funeral industry has had its share. But they are iso-    they are the ones who are “supposed to” take the
lated cases and are eventually caught, prosecuted,       body and prepare it.
and fined or jailed, often by people within the indus-       Young separates typical illegal or highly unethi-
try itself. When consumer groups talk about funeral      cal practices within the funeral industry (substitu-
“fraud,” they are most concerned with over-zealous       tion of merchandise, bait and switch, charging for
salesmen and a stretching of the truth in advertising    services not needed) from “subtle persuasion”—the
that causes bereaved families to spend much more         funeral director’s technique for increasing your
money than they either want or need to spend.            desire to spend more. “If the funeral director uses
Although the Federal Trade Commission (FTC) does         phrases like, ‘This is the final tribute you can give to
try to monitor the funeral industry, watchdog groups     your father,’ or ‘You only have one chance to do
warn that the FTC has so limited a staff that they are   this right for Mom,’ bells and whistles should go off
unlikely to go after cases of non-compliance unless      in your head. You are being told that you should
reported by the public first. In 2000 a U.S. Senate       think nothing of spending more money.”
hearing exposed a small but alarming pattern of cor-        The Federal Bureau of Investigation (FBI) offers
ruption and consumer fraud. Although relatively          these tips on avoiding funeral and cemetery fraud:
few consumer complaints about the funeral industry
are submitted, testimony before the committee sug-       • Be an informed consumer. Take time to call and
gested many problems may go unreported. A Cali-            shop around before making a purchase. Take a
fornia official said his state has only two inspectors      friend with you who may offer some perspective
to keep tabs on 890 funeral homes.                         to help make difficult decisions. Funeral homes
   After a six-month investigation, Consumers Digest       are required to provide detailed price lists over
concluded that pre-need plans are especially fraught       the phone or in writing. Ask if their lower priced
with potential for fraud:                                  items are included on their price list.
118 functional death

• Be informed about caskets before you buy one. It             death of loved ones with some type of ceremonial
  is a myth that funeral providers can determine               leave-taking. But today’s American and Canadian
  how long a casket will preserve a body.                      funeral is much different from the ceremony of only
• Research funeral home service fees when shop-                a few generations ago.
  ping for products elsewhere. Some of these                      In the past, funerals tended to be very plain, usu-
  charges are prohibited by the Federal Trade Com-             ally held in the home after family and friends pre-
  mission.                                                     pared the body, and followed by a short drive to the
                                                               local church cemetery for burial in a plain pine box.
• You should know that embalming is not legally
                                                               As Schvaneveldt writes, “This is in dramatic contrast
  required and that a casket is not needed for direct
                                                               to the modern funeral that is carried out by profes-
  cremations.
                                                               sionals who transform the dead body into a living
• Do not be pressured by high-priced pitches from              memorial.”
  funeral industry vendors.                                       Today’s funeral ranks among the most expensive
• Require all proposed plans and purchases to be               purchases many consumers will ever make. An
  put in writing.                                              average basic funeral cost $5,020 in 1998, up 5 per-
• Remember to carefully read contracts and pur-                cent from the previous year, although “extras” like
  chasing agreements before signing. Find out if               flowers, obituary notices, acknowledgment cards,
  agreements you sign can be voided, taken back,               or limousines can add thousands of dollars to the
  or transferred to other funeral homes.                       bottom line. Many funerals run well over $10,000.
                                                               Funeral and burial expenses have risen faster than
• Before you consider prepaying, make sure you
                                                               inflation since 1990.
  are well-informed. When you do make a plan for
                                                                  A traditional funeral today includes a casket,
  yourself, share your specific wishes with those
                                                               preparation and transportation of the body, use of
  close to you.
                                                               facilities for viewing and/or services, a religious rite
Horn, Miriam. “The Deathcare Business: The Goliaths of         and graveside service, the services of a funeral direc-
   the Funeral Industry are Making Lots of Money Off           tor, an outer burial container, and various ancillary
   Your Grief.” U.S. News & World Report, March 23, 1998.      items such as death certificate and flowers. Burial
Mitford, Jessica. The American Way of Death Revisited. New     costs will likely not be included in the funeral costs.
   York: Alfred A. Knopf, 1998.                                   But “traditional” may not be for long. As the
Wasik, John F. “Fraud in the Funeral Industry.” Consumers      baby-boomer generation approaches the age when
   Digest 34, no. 5 (September–October 1995): 53–59.           they are coming to grips with their own mortality,
Young, Gregory W. The High Cost of Dying: A Guide to Funeral   they are changing funerals much as they have
   Planning. Buffalo, N.Y.: Prometheus Books, 1994.            changed every other market they have encoun-
                                                               tered. Cullen writes, “The funeral is getting a make-
                                                               over as a growing number of Americans have begun
functional death Vital organs no longer operate                thinking outside the box, so to speak, about how
naturally; no heart beat or respiration, with vital            they want to say goodbye to their loved ones. Not
functions being sustained by artificial means.                  for them the weepy, organ-heavy ceremonies of
                                                               their parents and grandparents. Funerals today are
                                                               less about mourning a death than about celebrating
funeral A ceremony held in conjunction with the                a life. Custom-made coffins reflect the departed’s
burial or cremation of a dead person, often religious          devotion to NASCAR or deep-sea fishing. Harleys or
in nature. William Lamers, one of the first physi-              Corvettes lead processions in place of hearses.
cians to develop a hospice program in the United               Wakes are staged as garden parties and feature pro-
States, defined the funeral as “an organized, pur-              fessionally made biopics of the deceased. Cremated
poseful, time-limited, flexible, group-centered                remains are fashioned into jewelry, fused into art-
response to death.” As far back into history as we             work, and stuffed into fireworks for those who want
can explore, human beings have mourned the                     an exit with a real bang. There’s not a cookie-cutter
                                                                                      funeral parlors/homes 119

funeral anymore.” In response, she says, funeral               (802) 865–8300
directors have become more like event planners,                (800) 765–0107 (toll free)
complete with prop rooms and talk about their                  http://www.funerals.org
“production quality.”
   See also DEATHCARE INDUSTRY; FUNERAL SERVICE                   See also MEMORIAL SOCIETY.
CONSUMER ASSISTANCE PROGRAM; MEMORIAL SERVICE.

Cullen, Lisa Takeuchi. “What a Way to Go: Death-Defying        funeral director One whose business is the man-
   Rites Are Making Funerals More Personal and—Dare            agement of funerals. The more modern term for
   We Say It?—More Fun.” Time, July 7, 2003.                   UNDERTAKER. Also called mortician.
Funeral Consumer Alliance. “Twelve Reasons People Spend
   ‘Too Much’ for a Funeral.” Available online. URL: http://
   www.funerals.org/personal/toomuch.htm. Downloaded           funeral homes     See FUNERAL PARLORS/HOMES.
   July 18, 2003.
Mansell, John S. The Funeral: A Pastor’s Guide. Nashville,
   Tenn.: Abingdon Press, 1998.                                funeral leave    See BEREAVEMENT LEAVE.
Schvaneveldt, Jay D. Remembering at Death: Funeral and
   Related Rituals. Logan: Utah State University, 1989.
                                                               funeral mass    See MASS OF CHRISTIAN BURIAL.

funeral board     Each state except Colorado and
Hawaii has a funeral board or agency that regulates            funeral parlors/homes Immigrants arriving in
funeral directors. About half the states have some             America took up residence in the large cities and
sort of cemetery regulation.                                   lived in small apartments. When those families
                                                               experienced the death of a family member, they
                                                               had no parlor in which to hold the wake. In
Funeral Consumers Alliance (FCA) A federation                  response to that need, businessmen in the large
of consumer information societies dedicated to pro-            cities opened funeral parlors that families could rent
tecting a consumer’s right to choose a meaningful,             for their wake and funeral. In the outlying com-
dignified, affordable funeral. These societies are             munities, the tradition of home-based wakes and
nonsectarian, nonprofit, educational organizations              funerals continued until the early 1900s when
that were started in the late 1930s (known as                  undertakers began offering their homes for wakes
memorial societies) because of two influences: the              and funerals—and thus was born the American
depression and the increasing cost of funerals due to          funeral home.
the use of embalming and more elaborate manu-                      In the beginning, the funeral “business” took
factured caskets. There are now approximately 115              place on the ground floor of the undertaker’s home,
group members located throughout the United                    with his family residing on the upper floors. Even-
States; the number fluctuates because all groups are            tually, as the industry changed and the “under-
volunteer run. Until 1980 Canadian groups were                 taker” became a mortician or funeral director,
also members of FCA, but broke off after the U.S.              providing more of the services (embalming, flowers)
Federal Trade Commission laws changed, making                  themselves rather than simply arranging that these
the American funeral industry regulation too dis-              all get done, the funeral home’s space requirements
parate for FCA to continue to be a single organiza-            grew in order to accommodate embalming rooms,
tion for both Americans and Canadians. Contact                 casket display areas, chapels, and so on. The mod-
information:                                                   ern funeral home may still look like a “home,” but
Funeral Consumers Alliance                                     it is usually a multifaceted business.
33 Patchen Road                                                    Those early funeral parlors or homes were estab-
South Burlington, VT 05403                                     lished during a time when death happened earlier
120 funeral planning

in life and often at home, so people were more               offered by several funeral providers. It also spares
accustomed—and more comfortable—with it. Dur-                your survivors the stress of making these decisions
ing the past generation, when both longer lifespans          under the pressure of time and strong emotions.
and more geographically spread families—with the                You can make arrangements directly with a
elderly living apart from the family in some kind of         funeral establishment or through a funeral plan-
assisted living facility—have led to a distance from         ning or memorial society—a nonprofit organiza-
death and the dying, people are not as quick to              tion that provides information about funerals and
accept funeral homes in their neighborhoods.                 disposition but doesn’t offer funeral services. If you
Founders of some planned cities, such as Reston,             choose to contact such a group, recognize that
Virginia, for example, “forgot” to even include              while some funeral homes may include the word
cemeteries. In some more “fastidious” suburbs such           “society” in their names, they are not nonprofit
as Fairfax, Virginia, only a handful of funeral homes        organizations.
are allowed, in part, Whoriskey writes, “because                One other important consideration when plan-
officials, in their zeal to protect prosperous enclaves       ning a funeral is where the remains will be buried,
from every unpleasantness, have excluded the busi-           entombed or scattered. In the short time between
ness of death from much of the county. Funeral               the death and burial of a loved one, many family
homes are increasingly viewed as objectionable.”             members find themselves rushing to buy a ceme-
                                                             tery plot or grave—often without careful thought
Moore, Rob. “The American Funeral.” Clay County              or a personal visit to the site.
  Genealogical Society, Center Point, Indiana. Available        You may wish to make decisions about your
  online. URL: http://www.ccgsilib.org/american_             arrangements in advance, but not pay for them in
  funeral.html. Downloaded July 17, 2003.                    advance. Keep in mind that over time, prices may
Whoriskey, Peter. “Fairfax Code Keeps Death at a Dis-        go up and businesses may close or change owner-
  tance.” Washington Post, December 28, 2002.                ship. However, in some areas with increased com-
                                                             petition, prices may go down over time. It’s a good
                                                             idea to review and revise your decisions every few
funeral planning Many couples and families avoid             years, and to make sure your family is aware of
the subject of death, leaving the funeral decisions to       your wishes.
others. If death follows a lengthy terminal illness,
there will be time for thoughtful funeral planning.        Federal Trade Commission. “Funerals: A Consumer’s
But too often, death is sudden and unexpected.                Guide.” Available online. URL: http://www.ftc.gov/
With no planning ahead of time, the bereft family is          bcp/conline/pubs/services/funeral.htm. Posted June
especially susceptible to poor decision-making and            2000.
high-pressure sales tactics of the deathcare industry.     Funeral Consumers Alliance. “Twelve Reasons People
According to Funeral Consumers Alliance, lack of              Spend ‘Too Much’ for a Funeral.” Available online.
planning is a primary cause of high funeral costs.            URL: http://www.funerals.org/personal/toomuch.htm.
“When Mom dies, it may be altogether too easy to              Downloaded July 18, 2003.
say, ‘I want one just like Dad’s funeral,’ without         Young, Gregory W. The High Cost of Dying: A Guide to
looking at the actual cost. Many people feel so dev-          Funeral Planning. Buffalo, N.Y.: Prometheus Books,
astated and overwhelmed at a time of death that               1994.
they leave all funeral planning to the funeral direc-
tor. That’s like giving them a blank check.”
   The Federal Trade Commission offers funeral             funeral pyre Wood heaped for burning a dead
planning guidelines, including:                            body as a funeral rite. Used since ancient days, the
                                                           funeral pyre continues today in certain cultures,
   Thinking ahead allows you to choose the specific         especially in Asia, as a form of public cremation and
   items you want and need and compare the prices          religious ceremony. Constance Jones explains in
                                                                                        funerary mounds 121

R.I.P. (HarperCollins, 1997) that “bodies placed              Many funeral providers offer various “packages”
on funeral pyres are usually covered in some way.          of commonly selected goods and services that make
Aboriginal Australians painted bodies with red             up a funeral. But when you arrange for a funeral,
ocher. The Babylonians covered bodies with cloth           you have the right to buy individual goods and serv-
that could easily catch fire and then placed them in        ices rather than having to accept a package that may
clay coffins inside the funeral pyres.” Until outlawed      include items you do not want. Also, according to
by British colonial rulers, Hindu Indian widows            the Funeral Rule, if state or local law requires you to
were coerced by their in-laws to throw themselves          buy any particular item, the funeral provider must
upon their husbands’ funeral pyres in a ritual sui-        disclose it on the price list, with a reference to the
cide known as suttee. Today’s Hindu women per-             specific law; the funeral provider may not refuse, or
form a symbolistic suttee by prostrating themselves        charge a fee, to handle a casket you bought else-
on their husband’s funeral pyre until just prior to its    where; and a funeral provider that offers cremations
lighting.                                                  must make alternative containers available.


Funeral Rule    A federal regulation issued in 1984,       Funeral Service Consumer Assistance Program
then updated in 1994, that protects consumers; it is       (FSCAP) A nonprofit consumer service designed
enforced by the Federal Trade Commission (FTC).            to help people understand funeral service and
Not every state has adopted the rule, so where not         related topics and to help them resolve funeral serv-
enforced by state regulations, any complaints must         ice concerns. FSCAP service representatives and an
go to the federal level. Lisa Carlson, in Caring for the   intervener assist consumers in identifying needs,
Dead, says, “Generally, however, the FTC acts only         addressing complaints, and resolving problems.
when there’s a pattern of mischief, not on single          FSCAP does not arbitrate disputes or have enforce-
violations or on behalf of individuals. It is never-       ment or disciplinary authority to govern any aspect
theless important to send copies of any complaints         of funeral services, including pre-need. The pro-
to the FTC.”                                               gram is recognized by the U.S. Federal Trade Com-
   The Funeral Rule requires funeral directors to          mission. Free brochures on funeral related topics
provide the buyer itemized prices in person and, if        are available. Contact:
asked, over the phone. The rule also requires
                                                           Funeral Service Consumer Assistance Program
funeral directors to give other information about
                                                           P.O. Box 486
their goods and services. For example, if you ask
                                                           Elm Grove, WI 53122–0486
about funeral arrangements in person, the funeral
                                                           (708) 827–6337
home must give you a written price list to keep that
                                                           (800) 662–7666 (toll-free)
shows the goods and services the home offers. If
                                                           (262) 789–6977 (fax)
you want to buy a casket or outer burial container,
the funeral provider must show you descriptions of
the available selections and the prices before actu-
ally showing you the caskets.                              funerary mounds      See BURIAL MOUNDS.
                                                                                                             G
gas chamber     Instrument of execution consisting             on the following scales: Atypical Responses, Despair,
of a sealed chamber into which lethal poison gas is            Anger/Hostility, Guilt, Loss of Control, Rumination,
pumped. In 1924 the use of cyanide gas was intro-              Depersonalization, Somatization, Loss of Vigor, Phys-
duced in Nevada, which was looking for a more                  ical Symptoms, and Optimism/Despair. No signifi-
humane way of executing its inmates than by hang-              cant differences were found on the scales of Denial,
ing. When pumping the gas into the prisoner’s cell             Social Desirability, Social Isolation, Death Anxiety,
while he slept did not work (because the gas leaked            and Loss of Appetite.
from his cell), the gas chamber was developed.                     But Gilbert does see drawbacks with thinking in
When first used, deaths took anywhere from two to               terms of “women’s grief” and “men’s grief,” largely
11 minutes. Today, five states (Arizona, California,            because that viewpoint rarely reflects the reality of
Maryland, Missouri, and Wyoming) authorize lethal              life. “More realistically, what exists is gender-based
gas as a method of execution, but all have lethal              tendencies. A more accurate statement would be
injection as an alternative method. A federal judge            that ‘Men, in general, tend to be more. . . . while
in California ruled in 1994 that the gas chamber is            women tend, in general, to be more . . .’”
an inhumane method of punishment and thus out-
lawed the practice in California. Currently, lethal            Chen, J. H., et al. “Gender Differences in the Effects of
injection is administered in California unless the                Bereavement-Related Psychological Distress in Health
inmate requests the gas chamber.                                  Outcomes.” Psychological Medicine 29, no. 2 (March
                                                                  1999): 367–380.
                                                               Schwab, R. “Gender Differences in Parental Grief.” Death
gender differences in grief        In her course on               Studies 20, no. 2 (March–April 1996): 103–113.
“Grief in a Family Context,” Kathleen R. Gilbert,
Ph.D., Indiana University, notes that “until the past
few decades, little attention was paid to gender as a          genocide Systematic killing of a racial, ethnic, cul-
factor in grief and grieving. ‘Normal’ grief was               tural, or political group. The horror of the Holo-
assumed to follow a particular pattern.” However,              caust of World War II, when Hitler set about
she says, gender and gender role expectations are              exterminating the Jews, propelled the nations of
now recognized as important factors in grief.                  the world to declare genocide a punishable crime
   In their study of 150 widows and widowers,                  under international law. On December 9, 1948, the
Chen et al. concluded that there appear to be gen-             United Nations General Assembly adopted the Con-
der differences in the levels of psychological symp-           vention for the Prevention and Punishment of the
toms resulting from bereavement and in the effects             Crime of Genocide. “Genocide” was a new word,
of bereavement on subsequent mental and physical               coined after the events of World War II.
health for widows and widowers.
   Schwab examined gender differences in the grief
of parents who lost their child, using the Grief Expe-         ghost Generally considered to be the visible dis-
rience Inventory. Results showed that the mothers’             embodied soul of a dead person; also called specter,
scores were significantly higher than those of fathers          apparition, or phantom. The belief in ghosts is

                                                         123
124 ghost sickness

ancient and widespread. Although most religions               and someone who has died, sometimes associated
do not officially acknowledge the existence of                with witchcraft; frequently observed among mem-
ghosts, Boston College philosophy professor and               bers of many American Indian tribes. Symptoms
Christian writer Dr. Peter Kreeft, author of Every-           include nightmares, weakness, anxiety and feelings
thing You Ever Wanted to Know about Heaven (Ignatius          of danger, poor appetite, dizziness and fainting, hal-
Press, 1990), writes, “There is enormous evidence of          lucinations, loss of consciousness, confusion, feel-
‘ghosts’ in all cultures. . . . Even taking into account      ings of futility, and a sense of suffocation.
our penchant to deceive and be deceived, our
credulity and fakery, there remain so many trust-             American Psychiatric Association. Diagnostic and Statistical
worthy accounts of ghosts—trustworthy by every                  Manual of Mental Disorders, Fourth Edition (DSM-IV).
ordinary empirical and psychological standard—that              Washington, D.C.: American Psychiatric Association,
only a dogmatic prejudice against them could pre-               1994.
vent us from believing they exist.”
    According to Leslie Spier, University of New
Mexico, “In cultures that worship ancestors, ghosts           good death A “good death” is one that is free
are not considered ancestral dead, but identities             from avoidable distress and suffering for patients,
who are impersonal, unidentifiable, unpredictable,             families, and caregivers. A good death is also in gen-
inimical, or malignant. Such acts as ridding houses           eral accord with the patients’ wishes and reasonably
of the spirits of the dead or foiling ghosts, are com-        consistent with clinical, cultural, and ethical stan-
mon, but they are magical acts rather than rites of           dards. Dr. Tony Back, University of Washington and
worship and reverence.”                                       VA Puget Sound Health Care System, says a good
    Some individuals fear ghosts because they are             death is more than proper medical treatment.
supernatural phenomena and involve a fear of the              “What people choose when they think about a good
unknown. Doctor and Kahn explain, “The fear of                death for themselves is often beyond what medicine
ghosts may have been planted in the minds of prim-            can provide—for instance, an affirmation of love, a
itive man because of concern about the afterlife of           completion of important work, or a last visit with an
deceased relatives. Dead ancestors, who were wor-             important person. As a physician, I can’t always
shiped in many early cultures as gods or near-gods,           make those things happen.”
were thought to be easily angered. Gifts and cere-               In one study of 77 physicians, nurses, social
monies were necessary to sustain their goodwill and           workers, chaplains, hospice volunteers, patients,
decrease hostilities the dead were believed to bear           and recently bereaved family members, the con-
toward the living. Belief in and fear of ghosts was           sensus drawn was that a good death involves health
furthered by desires for a pleasant afterlife, a heaven       care providers who attend to the patient’s fears of
or Elysian fields, accessible to some but not all spir-        dying in pain, the participation of patients in deci-
its. Criminals and witches were condemned to walk             sion making, patients knowing what will happen
the earth rather than enter a restful existence after         during the dying process and afterward, and a sense
death. The spirits of murder victims or individuals           of completion by spending meaningful time with
who had been buried improperly could not rest in              loved ones and paying attention to spiritual beliefs.
peace until the wrong had been righted. Burial cus-           A recurring theme was the importance of treating
toms and rituals indicate a desire to keep the spirits        the patient as a unique, whole person and not a
of the dead away from the living.”                            disease or case.
                                                                 According to Thomas, whether or not a person
Doctor, Ronald M., and Ada P. Kahn. “Phasmophobia,” in        dies a “good death” can have a profound effect on
  The Encyclopedia of Phobias, Fears, and Anxieties, Second   the family. “For many cultures, how the surviving
  Edition. New York: Facts On File, 2000.                     members cope with the grief and loss of the death
                                                              experience is based on their perception of whether
                                                              or not the deceased had a good death. For many in
ghost sickness A culture-bound syndrome                       the African-American community, the concept of
described in DSM-IV as a preoccupation with death             good death refers to whether the individual was able
                                                                                                       grave liner 125

to have some control over the dying process and                 bottom, but once the casket and liner or vault are in
bring orderly closure to the end-of-life experience.”           place, only two or three feet of dirt will be between
                                                                them and the ground level. “Double depth” graves,
Back, Tony. “End-of-Life Issues.” Ethics in Medicine, Uni-      for the interment of two people, are allowed in
   versity of Washington School of Medicine. Available          many cemeteries, where one casket is placed in the
   online. URL: http://eduserv.hscer.washington.edu/            grave at an approximate depth of seven feet. When
   bioethics/topics/eol.html. Downloaded July 20, 2003.         a second interment is required, the second casket is
Thomas, Norma D. “The Importance of Culture Through-            placed on top of the first casket at standard depth.
   out All of Life and Beyond.” Holistic Nursing Practice 15,      The Web site “Find a Grave” (http://www.
   no. 2 (January 2001): 40–46.                                 findagrave.com) allows visitors to virtually search
                                                                for the graves of famous people as well as those of
                                                                their own family and ancestors.
Grace Project, The       A collaboration of individuals
and organizations working to promote high-quality
end-of-life care for terminally ill inmates in prisons          graveclothes   The clothes or dress in which the
and jails. Historically, end-of-life care has not been          dead are buried.
a high priority for correctional facilities because of            See also BURIAL CLOTHES; SHROUD.
the low number of inmates who face their final days
in confinement. But the AIDS epidemic, followed
by the passage of tough sentencing laws, com-                   grave liner     Also known as a burial container, a
pounded by the shear growth in incarceration, has               grave liner or burial VAULT is commonly used in a
dramatically increased the number of deaths occur-              traditional, full-service funeral. The vault or liner is
ring in prison. More than 2,500 prisoners died of               placed in the ground before burial, and the casket is
natural causes in state and federal correctional                lowered into it at burial. The purpose is to prevent
facilities in 1998. With longer sentences and limited           the ground from caving in, especially during the
use of medical parole and compassionate release,                first year after burial when the soil compacts signif-
the number of terminally ill inmates is expected to             icantly, then as the casket deteriorates over time. A
grow as the older inmates age in place. Contact                 grave liner is made of reinforced concrete and cov-
Information:                                                    ers only the top and sides of the casket.
Volunteers of America—National Office                               The Federal Trade Commission warns that state
1660 Duke Street                                                laws do not require either a vault or liner, and
Alexandria, VA 22314–3427                                       funeral providers may not tell you otherwise. “How-
(800) 899–0089                                                  ever, keep in mind that many cemeteries require
(703) 341–7001 (fax)                                            some type of outer burial container to prevent the
graceprojects@voa.org                                           grave from sinking in the future. Neither grave lin-
http://www.graceprojects.org                                    ers nor burial vaults are designed to prevent the
                                                                eventual decomposition of human remains. It is ille-
                                                                gal for funeral providers to claim that a liner or vault
grave A place for the burial of a corpse, especially            will keep water, dirt or other debris from penetrat-
beneath the ground. When a grave is marked by a                 ing into the casket if that’s not true.”
protective or memorial structure it is often referred              Carlson adds that Jewish and Muslim cemeteries,
to as a TOMB. The depth of a grave is governed more             honoring their tradition of returning to the earth,
often by cemetery regulations than by state law.                rarely require a grave liner or vault, and warns also
The “six feet under” description of a grave goes back           about potential deceptive sales policies. “A grave liner
to a time in our history when people were not                   is about half the price of a coffin vault, but many
buried in grave liners or vaults, and sometimes not             funeral directors claim they ‘stock’ the vaults only.”
even in caskets. Six feet was considered deep
enough to prevent animals from digging up the                   Carlson, Lisa. Caring for the Dead: Your Final Act of Love.
grave. Today, a grave may be six feet deep at the                  Hinesburg, Vt.: Upper Access Books, 1998.
126 grave marker

grave marker     Something placed in remembrance         into the netherworld. Koop adds that, similarly, the
of the dead at the grave. Grave markers may be           plunder of Peru’s relics began with the Spanish con-
temporary, such as a plaque or stake to mark the         quest and has become part of Peru’s culture. “For
grave while a more permanent marker is bring             centuries, ancient Peruvian graves full of archaeo-
made, or permanent, such as a GRAVESTONE (HEAD-          logical treasures were seen as mines to exploit and
STONE or footstone), cross, bench, statue, or tomb-      only in the last 30 years has legislation sought to
stone. Originally, grave markers were simply piles of    control the traffic. In 1938, in the greatest known
stones, with another stone added by each person          plunder of the century, the owner of Batan Grande,
who visited the grave site. Without the buildup of       a hacienda 30 miles north of Sipan, used a bull-
stones, the elements would gradually make the            dozer to break open a pyramid and is said by wit-
grave site difficult or impossible to find. Around the     nesses to have extracted 15 potato sacks full of gold
eighth century B.C.E., the Greeks used large deco-       artifacts.”
rated pots to mark graves. Old cemeteries tend to
have upright grave markers; new cemeteries (post-        Koop, David. “Grave Robbing Is Link to Underground
1960) tend to have flat bronze markers on a stone            Trade.” Associated Press, 1997.
or cement base.                                          Seabrook, Charles. “The Body Snatchers of Augusta.” The
                                                            Atlanta Journal and Constitution, March 8, 1998.

grave robbing The fear of the desecration of bur-
ial sites is both ancient and widespread, as expressed   gravestone    A stone placed on a grave to mark it,
by the care with which the Egyptians prepared and        often bearing an inscription listing years of birth
protected the bodies of their dead from all harm.        and death, name, and perhaps an EPITAPH. Accord-
The late-18th-century shortage of cadavers for legit-    ing to the Connecticut Gravestone Network, the
imate medical research and dissection posed a prob-      earliest grave markers used in many first settle-
lem for scientists and students, some of whom took       ments of America were made of wood or simple
to grave robbing for their corpses. In 1789 New York     fieldstone. The larger cities, for example Boston,
passed a law making it possible for doctors to obtain    Massachusetts, and Newport, Rhode Island, had
cadavers without resorting to body-snatching. A          established communities with large populations that
similar bill was passed in London in 1832.               would support economically a full-time business of
    Many African Americans were victims of a             making or providing coffins and gravestones. Most
grave-robbing ring that clandestinely supplied           gravestones were made by stonemasons or quarry
medical students at the Medical College of Georgia,      holders who also traded in architectural features
Augusta, with illegal cadavers during the 19th cen-      such as foundation stone for buildings and bridges,
tury, the grave robbers receiving $10 to $20 per         mantels, doorjambs and fireplaces. In cities like
body. Seabrook writes, “Many blacks, especially the      Boston and Newport, the works of craftsmen like
poor, avoided medical help during the grave-robber       the Stevens family were well known and are found
era because they feared getting bad treatment,           all the way down the coast to Charleston, South
dying and being dissected. That fear prompted            Carolina. These eloquent and elaborately carved
them to rely more on African-based folk remedies         slates were often shipped to other ports to fill the
than on conventional medicine. Even today, that          need for those who could afford to do so. Poorer
legacy lingers, and may be why many African-             local folk would do with what they could until a
Americans, especially the elderly, distrust the med-     man of skill would join their community or at least
ical establishment.”                                     would pass through and stay long enough to fill
    Grave robbing for mercenary purposes dates back      some orders. The Stevens shop of Newport is the
at least as far as the ancient Egyptians, when grave     oldest established gravestone carving business in
robbers looted the relatively fresh tombs of the         America—still producing slate memorials as it did in
pharaohs and lower nobility looking for valuables        the 1600s. But most gravestones today are engraved
that were buried with the dead for their journey         using state-of-the-art laser etching.
                                                                                        Greeks, ancient 127

gravestone rubbing The practice of using various          community and church plots. That same idea was
materials to obtain the relief impression of lettering,   passed on to smaller plantations and family farms,
carving, or designs from a gravestone. Gravestone         with the model following into the early 20th century.
rubbing is believed to have originated with the           Other states have the similar challenge of finding and
ancient Chinese who used “temple rubbing” as a            mapping centuries-old graveyards—sometimes with-
way of communicating the “written word” and is            out markers or overgrown with vegetation—to pro-
considered a forerunner to the printing press.            tect them from developers who have no way of
Gravestone rubbings create a useful record of fam-        knowing they are there.
ily information and funerary symbolism. Sometimes
a rubbing becomes the only permanent reproduc-            Amon, Michael. “Reclaiming Forgotten Family Grave-
tion of gravestones that deteriorate over time or           yards.” The Washington Post, July 8, 2001.
because of vandalism. For this reason, gravestone
rubbing has become popular among genealogists
and folklorists as well as historians. Ornate grave-      Greeks, ancient Many Greeks died because of
stones from the Victorian era are especially “desir-      childhood diseases, making the average life span
able” for rubbing. However, gravestone rubbing is         only 25 years, although many Greeks lived to age
becoming controversial—even outlawed in some              80. Much of what we know about the ancient
places, in order to prevent further damage to the         Greeks comes from their burials, as they often
gravestones. A leaflet, “Gravestone Rubbing for           buried dead people with some of their possessions
Beginners,” is available from:                            and marked graves with carved gravestones. Grave-
                                                          yards were outside the walls of a city to keep wan-
Association for Gravestone Studies
                                                          dering spirits away from the living
278 Main Street
                                                             The ancient Greeks believed in reincarnation,
Suite 207
                                                          enclosing information in the tomb of the deceased
Greenfield, MA 01301
                                                          regarding negotiating the underworld. They also
(413) 772–0836
                                                          placed coins under the tongues of corpses for
info@gravestonestudies.org
                                                          Charon, the boatman who took them across the
   See also SYMBOLISM ON GRAVESTONES.                     river Styx to the land of eternity, and enclosed honey
                                                          cakes next to the bodies in their tombs as an offer-
Karrick, Katie. “What Is a Gravestone Rubbing?” America   ing to Cerberus, the three-headed dog who guarded
   Online Members. Available online. URL: http://mem-     the entrance to HADES. The dead were often buried
   bers.aol.com/TombView/rubbings.html. Downloaded        with some of their belongings, such as jewelry, per-
   July 21, 2003.                                         fume, pots of make-up, and tools for spinning and
                                                          weaving for the women; weapons for the men.
                                                             Interment was delayed three days to prevent pre-
graveyard     A tract of land used for burial. Grave-     mature burial, then the procession to the burial
yards became CEMETERIES about the same time               tomb was followed by wailing mourners with the
undertakers became funeral directors, as Americans        wealthy sometimes hiring extra people to follow
began distancing themselves from things death             the procession, weeping and wailing and tearing at
related and the industry cooperated by changing           their hair and clothes (a sign of mourning to the
the nomenclature.                                         Greeks). The wealthiest would have private family
   As cities expand into the suburbs and swallow up       tombs, with the walls and floors decorated with
rural countryside, early church and family grave-         mosaic tiles. Cremation came into practice about
yards are “found” and cause road rerouting or build-      300 B.C.E., after which ashes of the dead were
ing replanning, particularly in the South. Amon           buried in a jar or container made of marble. Richer
explains that in 1623, the Virginia House of Bur-         families would then set up a tombstone, which
gesses passed a law requiring large plantations to        would be decorated with pictures or inscriptions
have graveyards, eliminating the need for large           about the person. Families visited graves once a year
128 green burials

for special prayers and offerings to the dead of food,    grief    A normal but intensely powerful, painful,
wine, and oil, and to tend to the graves.                 and stressful emotional reaction caused by the loss
                                                          of a loved one or of something with very important
                                                          personal significance in an individual’s life; grief is a
green burials Also called woodland burials or             type of suffering and a symptom of BEREAVEMENT.
green funerals; an environmentally sensitive burial       An ACUTE GRIEF REACTION may come considerably
option popularized in Britain. Green burial grounds,      after the loss or traumatic event, or it may not come
which are located in woodland or meadows, are             at all in the manner expected. Although the expres-
kept as wild and as natural as possible, with memo-       sion of grief is unique to each individual, there are
rials and headstones not permitted, although              recognized STAGES OF GRIEF that include some com-
memorial trees or shrubs can usually be planted or        mon characteristics.
indigenous stones placed, to mark the graves. Bur-            Many people who have experienced loss say that
ial locations may be mapped with a GIS (geographic        it can take up to two years to adjust and get on with
information system), allowing future generations          life. However, overwhelming feelings of loss do
to locate an ancestor’s final resting place. In a green    recur. In the long run, a positive attitude can help
burial, no toxic embalming fluids are used, and the        overcome depressed feelings and the stresses of
body is buried in a coffin made from biodegradable         adjustment.
materials, such as willow or chipboard, or a “lovely          A support system often influences how well an
woollen shroud.” Proponents add that traditional          individual adjusts after a period of grief. The recov-
cemeteries must be cared for using air-polluting          ery process may be accelerated with friends and
lawn mowers, fertilizers, and weed killers. A green       family nearby. Widowed persons with no relatives
cemetery also protects and preserves open space           and few friends seem to have the most difficult time
from future development. The green funeral option         adjusting to the death of a loved one. Some parents
continues to grow in popularity in England, with          who have lost an infant try to have another baby
about 200 woodland burial sites around the country.       within a few years; however, the feeling of loss of
    The United States has been slow to follow; cyn-       the first one never really goes away.
ics say this is due to the lower profits for the death-        See also COMPLICATED GRIEF REACTION; PREPARA-
care industry, but consumers must buy into the            TORY GRIEF.
concept of no embalming and less protection for
the body. The first green cemetery in the United           Kahn, Ada P. “Grief,” in Stress A to Z. New York: Facts On
States was Ramsey Creek preserve, in Westminster,           File, 1998.
South Carolina, with its first burial in 1998. Other
states offering or in the process of establishing green
burial sites include Florida, Colorado, California,       grief counseling and therapy Most of the sup-
New York, Washington, and Wisconsin. American             port that people receive after a loss comes from
green cemeteries are more likely to allow head-           friends and family, although doctors and nurses
stones than are those in England.                         may also be a source of support. For people who
    The Natural Death Centre is a charitable project      experience difficulty in coping with their loss, grief
launched in Britain in 1991 to help people arrange        counseling or grief therapy may be necessary.
environmentally-friendly funerals. Its Web site URL          Grief counseling helps mourners with normal
is http://www.naturaldeath.org.uk. The center lists       grief reactions work through the tasks of grieving. It
U.S. and Canadian green burial information and            can be provided by professionally trained people, or
resources at http://www.naturaldeath.org.uk/              in self-help groups where bereaved people help
USAandCanadaResources.htm                                 other bereaved people. All of these services may be
                                                          available in individual or group settings.
Smith, Nancy. “Greener Ways to the Great Beyond.”            The goals of grief counseling include:
  Mother Earth News. Available online. URL: http://www.
  motherearthnews.com/index.php?page=rec&id=2052.         • Helping the bereaved to accept the loss by help-
  Posted April 2003.                                        ing him or her to talk about the loss
                                                                                              grief industry 129

• Helping the bereaved to identify and express feel-       the physical and emotional pain of grief, adjusting
  ings related to the loss (for example, anger, guilt,     to life without the loved one, and emotionally sep-
  anxiety, helplessness, and sadness)                      arating from the loved one and going on with life
• Helping the bereaved to live without the person          without him or her. It is important that these tasks
  who died and to make decisions alone                     are completed before mourning can end.
                                                              In grief therapy, six methods may be used to help
• Helping the bereaved to separate emotionally
                                                           a mourner work through grief:
  from the person who died and to begin new rela-
  tionships                                                1. Develop the ability to experience, express, and
• Providing support and time to focus on grieving at          adjust to painful grief-related changes.
  important times such as birthdays and anniversaries      2. Find effective ways to cope with painful changes.
• Describing normal grieving and the differences           3. Establish a continuing relationship with the per-
  in grieving among individuals                               son who died.
• Providing continuous support                             4. Stay healthy and keep functioning.
• Helping the bereaved to understand his or her            5. Reestablish relationships and understand that
  methods of coping                                           others may have difficulty empathizing with the
• Identifying coping problems the bereaved may                grief they experience.
  have and making recommendations for profes-              6. Develop a healthy image of oneself and the world.
  sional grief therapy
                                                           Not everyone needs grief counseling. Several
Grief therapy is used with people who have more            researchers have recently concluded that people who
serious grief reactions. The goal of grief therapy is to   share their thoughts and feelings following the death
identify and solve problems the mourner may have           of a loved one do not adjust to the loss any better
in separating from the person who died. When sep-          than those who do not, and people can quite suc-
aration difficulties occur, they may appear as phys-        cessfully on their own find ways of coping with loss.
ical or behavior problems, delayed or extreme              Psychologist Robert A. Neimeyer goes so far as to say
mourning, conflicted or extended grief, or unex-            that grief counseling and therapy are “typically inef-
pected mourning (although this is seldom present           fective, and perhaps even deleterious, at least for
following lengthy terminal illnesses such as cancer        people experiencing a normal bereavement.” He
deaths).                                                   does add, “On the other hand, there is some evi-
   Grief therapy may be available as individual or         dence that grief therapy is more beneficial and safer
group therapy. A contract is set up with the indi-         for those who have been traumatically bereaved.”
vidual that establishes the time limit of the therapy,
the fees, the goals, and the focus of the therapy.         Large, Elizabeth. “There May Not Be a ‘Best’ Way of Deal-
   In grief therapy, the mourner talks about the              ing with Grief.” Funeral & Estate Planning Guide. The
deceased and tries to recognize whether he or she is          Union Leader, April 11, 2003.
experiencing an expected amount of emotion about           National Cancer Institute. “Loss, Grief, and Bereavement.”
the death. Grief therapy may allow the mourner to             National Institutes of Health. Available online. URL:
see that anger, guilt, or other negative or uncom-            http://www.nci.nih.gov/cancerinfo/pdg/supportive-
fortable feelings can exist at the same time as more          care/bereavement/patient/. Posted July 9, 2003.
positive feelings about the person who died.               Neimeyer, Robert A. “Searching for the Meaning of Mean-
   Human beings tend to make strong bonds of                  ing: Grief Therapy and the Process of Reconstruction.”
affection or attachment with others. When these               Death Studies 24, no. 6 (September 2000): 541–558.
bonds are broken, as in death, a strong emotional
reaction occurs. After a loss occurs, a person must
accomplish certain tasks to complete the process of        grief industry The name used by many—a bit deri-
grief. These basic tasks of mourning include accept-       sively—to cover the recent media-driven emer-
ing that the loss happened, living with and feeling        gence of grief counseling services, from counselors
130 grief reaction

to therapists to self-help authors to psychologists to      care of others in the family, the desire to see or not
psychiatrists. Following national tragedies, such as        to see family or friends, or the desire to return to
the Oklahoma City bombing, Columbine shooting,              work. As with bereavement, grief processes are
and World Trade Center attacks, the grief industry          dependent on the nature of the relationship with
appeared to bloom, as 24-hour cable TV and corpo-           the person lost, the situation surrounding the loss,
rations by the dozen called on their services.              and one’s attachment to the person. Kahn describes
Although professional grief counseling can be of            these grief reactions this way:
immense help to certain individuals, authors cau-
tion that not all counseling is competent—or                   Numbness is a pervasive feeling that enables the
needed. Yale psychiatrist Sally L. Satel, who is also          mourner to get through the first few days following
a senior associate at the Ethics and Public Policy             the death of the loved one; it may last from a few
Center, writing in The New York Times, calls it “the           days to a few months.
commodification of grief.” She writes:                              Hallucinations are also common among the
                                                               recently bereaved; in some cases, they believe that
   The Grief Industry is apparently booming: bereave-          the dead person walks into the room or they see him
   ment books, grief chat rooms, expensive workshops           or her in a crowd. In the case of a deceased infant
   in grief education and exams for certification. You          or child, a parent may hear his or her cry or voice.
   need us, the experts say. But do we? Most people,               As the initial feeling of numbness begins to wear
   in fact, are quite resilient and don’t need registered      off, the individual may feel anger and despair and
   experts to deal with anguish. Are our priests and           feel overwhelmed by the circumstances; these feel-
   rabbis not up to the task? Are our families’ instincts      ings can lead to depression.
   to comfort not keen enough? The deployment of                   Physical symptoms are fairly common, including
   counselors—a well-meaning effort, I wholly grant            headaches, insomnia, or gastrointestinal com-
   you—sends an odd message: that people are too               plaints. Attempted suicide is an abnormal expres-
   fragile to soothe and strengthen themselves. Add to         sion of grief, but is not uncommon. There may be
   the tyranny of experts the tyranny of the news              an increase in use of tranquilizer drugs and alcohol
   media and you have an unholy therapeutic                    at this time.
   alliance. While grief counselors push people toward             The individual may experience intense feelings
   open self-expression, the microphones are on and            of helplessness. Questions arise: “Could I have pre-
   the cameras rolling. Making agony so public is              vented this from happening? Why wasn’t I power-
   unlikely to help their “clients.”                           ful enough to do something more?” Such thoughts
                                                               are part of the human condition. People like to feel
                                                               that they are in control at all times, and with grief
grief reaction Reaction to grief is the feeling of             they feel the loss of that control.
loss and anxiety an individual experiences when a
crucial bond is disrupted. Many individuals call into       As a result of a classic study following the Coconut
play their own defense mechanisms. These mecha-             Grove nightclub fire in Boston in 1942, five normal
nisms may help an individual cope with the pain of          stages of grief reaction were defined as: initial shock,
the loss. Normal grief reaction may be characterized        intense sadness, withdrawal from the environment,
by physical reactions, feelings of emptiness, preoc-        protest of the loss, and finally, a gradual resolution
cupation with images of the deceased, guilt feel-           of the loss. Doctor and Kahn add, “There is a higher
ings, or change in activity patterns. Thus, grief           death and illness risk for individuals for a year after
reactions can be psychological, emotional, physical,        they lose a spouse.”
or social. Psychological/emotional reactions can               Not every psychologist believes the long-held
include anger, guilt, anxiety, sadness, and despair.        truth that people must confront their feelings about
Physical reactions can include sleep difficulties,          the death of a loved one to adjust to the loss,
appetite changes, somatic complaints, or illness.           that those who do not are simply repressing their
Social reactions can include feelings about taking          emotions. Columbia University professor George
                                                                                                             guilt 131

Bonanno argues that there is no evidence for that                     of the loss. They try to find and bring back the
assumption. In his study, almost half of the                          lost person and feel ongoing frustration and dis-
bereaved showed no real symptoms of depression                        appointment when this is not possible.
after the loss; they had simply adjusted to their loss             3. Disorganization and despair family members
quickly and got back into the stream of things.                       feel depressed and find it difficult to plan for the
Other studies have essentially agreed with                            future. They are easily distracted and have diffi-
Bonanno’s findings, yet some scientists continue to                    culty concentrating and focusing.
argue that these apparently quick-to-adjust subjects
                                                                   4. Reorganization
are “just depressed and don’t know it.”
                                                                      See also STAGES OF GRIEF.
Bonanno, George. “Resilience to Loss and Chronic Grief:
   A Prospective Study from Pre-loss to 18 Months Post-
   Loss.” Journal of Personality and Social Psychology 83, no.
                                                                   Grim Reaper     Death personified as a tall, solemn-
   5 (November 2002): 1150–1164.
                                                                   looking old man or a skeleton wearing a long black
Doctor, Ronald M., and Ada P. Kahn. “grief reaction and
                                                                   cloak and cowl over its face, and carrying a scythe
   grief resolution,” in The Encyclopedia of Phobias, Fears, and
                                                                   with which he cuts off people’s lives as though he
   Anxieties, Second Edition. New York: Facts On File, 2000.
                                                                   were harvesting grain. He is said to appear at the
Kahn, Ada P. “grief,” in Stress A to Z. New York: Facts On
                                                                   moment of death to escort the newly deceased to
   File, 1998.
                                                                   the realm of the dead. Sometimes, the Grim Reaper
Large, Elizabeth. “There May Not Be a ‘Best’ Way of Deal-
                                                                   is pictured afoot; other times, he appears sitting
   ing with Grief.” Funeral & Estate Planning Guide. The
                                                                   upon a large black horse. Mythologists and ethno-
   Union Leader, April 11, 2003.
                                                                   graphers who study contemporary cultures debate
                                                                   the Grim Reaper’s origins, but he is generally
                                                                   believed to have sprung from ancient Greek and/or
grieving process, the  Those who work with griev-                  Roman mythology.
ing people talk about bereavement being a process
people must work through before they can focus on
the future. They do not mean that it is necessarily                guardianship Adult guardianship is a legal rela-
an orderly progression, but rather a series of emo-                tionship between a court-appointed individual or
tions to deal with. According to the World Health                  program (the “guardian”) and an individual who is
Organization, a helpful model is to think of four                  found by the court to be incapacitated (the “ward”)
tasks to be completed by the bereaved person:                      due to dementia, developmental disability, stroke,
                                                                   brain injury, chronic mental illness, or other causes.
• accepting the reality of the loss                                A court may grant guardianship for end-of-life deci-
• the patient possibly feeling numb                                sions such as refusing or consenting to medical
• experiencing the pain of grief                                   treatment, and making a will. The National
                                                                   Guardianship Organization is located at 1604 North
• adapting to the world without the deceased
                                                                   Country Club Road, Tucson, AZ 85716; http://
• “letting go” of the deceased and moving on.                      www.guardianship.org.

   The National Cancer Institute describes the griev-
ing process as having four phases:                                 guilt   Occasional feelings of guilt over failure to
                                                                   do something, or self-accusations over small inci-
1. Shock and numbness family members find it                        dents, are typical and normal emotions for the
   difficult to believe the death; they feel stunned                bereaved—and it does not always have a realistic
   and numb.                                                       basis. Cunningham explains, “Most people who
2. Yearning and searching survivors experience                     grieve experience some level of guilt. We put our-
   separation anxiety and cannot accept the reality                selves through the If onlys: If only I could have
132 guilt

prevented the death; If only I hadn’t had that argu-     longed and difficult, and the issues it raises can last
ment; If only I had said ‘I love you.’”                  a lifetime. Similarly, those who assist in a loved
   Some studies have shown that when children            one’s voluntary death may suffer debilitating guilt
experience the death of a close relative, such as a      and a prolonged and complicated bereavement.
brother, sister, or parent, they often feel guilty.         According to THE COMPASSIONATE FRIENDS, par-
While most of us experience some guilt when we           ents who lose their adult children also struggle with
lose a loved one, young children in particular have      guilt. “Most bereaved parents experience guilt for
difficulty understanding cause-and-effect relation-       having outlived their child. When adult children
ships. They think that in some way they caused           die as the result of suicide, drug use, driving drunk,
the death; maybe their angry thoughts caused the         AIDS, or other causes that are associated with a
person to die. Some children may view death as a         social stigma, many parents often experience an
punishment: “Mommy died and left me because I            even more intense sense of guilt for not having real-
was bad.”                                                ized that their child was having serious difficulties.
   Feelings of guilt can be particularly strong in       Parents often wonder what they could have done
teens, Cunningham says, but she cautions that it is      differently to prevent the situations that may have
usually a transitory stage. “Arguments are a part of     caused their child’s death.”
family life, especially during adolescence. Because of      Some feelings of guilt go beyond normal grief,
this fact, teenagers often experience extreme feel-      such as persistent and intrusive feelings of guilt (or
ings of guilt or take on responsibility for the death    thoughts that one should have died along with the
in some way. It is important that we do not try to       deceased loved one) are more characteristic of
‘fix’ their grief. Most teens simply need to tell you     depression than normal bereavement.
what they are feeling and, in time, the guilt, with
good support, can diminish.”                             Cunningham, Linda. “Grief and the Adolescent,” TAG:
   Evans and Farberow write that survivors of sui-          Teen Age Grief, Inc. Available online. URL: http://www.
cide are also especially prone to feelings of shame,        thevine.net/~tag/grief.html Downloaded March 3,
guilt, and self-blame. “The act itself immediately          2003.
raises obvious questions for them, such as ‘Why?’        Evans, Glen, Norman L. Farberow, and Kennedy Associ-
and ‘What could I have done to prevent it?’” For            ates. “survivor guilt,” in The Encyclopedia of Suicide, Sec-
this reason, bereavement after suicide is often pro-        ond Edition. New York: Facts On File, 2003.
                                                                                                                     H
Hades    Hades was the Greek god of the under-                    hallucination A false or distorted perception gen-
world; his equivalent in Roman mythology was                      erated in the mind, such as seeing people when no
Pluto. His domain—the kingdom of the dead—                        one is there (visual hallucination) or hearing voices
became known also as Hades, which was separated                   when no one is around (auditory hallucination).
from the land of the living by the river Styx. The                Research shows that especially for people recently
newly dead were ferried across the Styx by the fer-               bereaved, it is not an uncommon experience to hear
ryman Charon, whom they paid with the coins that                  the voice of or have a vision of the deceased person.
had been placed in their mouths when they were                    Although common in the early stages of grieving,
buried. Hades was guarded by the fearsome dog                     such perceptions usually disappear after a short time.
Cerberus, so Greeks also had honey cakes buried                   In a Swedish study of 50 people in their seventies
with them as a bribe to get by Cerberus.                          who had recently lost spouses, post-bereavement
                                                                  hallucinations or illusions were very frequent and
                                                                  considered helpful. Half of the subjects felt the pres-
Halloween       In Babylonian times, the day we now               ence of the deceased (illusions); about one-third
call Halloween marked the time when the dead                      reported seeing, hearing, and talking to the deceased
came back to life, according to Colgate professor                 (hallucinations).
Anthony Aveni, an archaeoastronomist who spe-                        Hallucinations also are common among the
cializes in the study of ancient rites, rituals, and cus-         dying themselves, and may be considered a symp-
toms. According to Aveni’s research, over the                     tom of the “confusion” stage of dying. These
centuries Halloween has held a significant place in                deathbed visions have been documented as includ-
many cultures and lands:                                          ing deceased relatives, angelic beings, and the per-
                                                                  ception of symbolic borders or limits, including
• Alexandrian Egyptians laid out food for the dead                water and heavenly gates; and have been inter-
  and fastened oil lamps to the eaves of their                    preted as being comforting to the dying.
  houses to commemorate them.
• Ancient Romans threw black beans at “spirits” in                Grimby, A. “Bereavement among Elderly People: Grief
  hopes that they would accept the beans instead of                  Reactions, Post-bereavement Hallucinations and Qual-
  carrying off living family members.                                ity of Life.” Acta Psychiatrica Scandinavica 87, no. 1 (Jan-
• The ancient Celts considered it a time when the                    uary 1993): 72–80.
  gates between the living and the dead opened.                   Houran, J., and R. Lange. “Hallucinations That Comfort:
  Bonfires burned to attract dead relatives and to                    Contextual Mediation of Deathbed Visions.” Perceptual
  scare those who might do harm.                                     and Motor Skills 84, no. 3, part 2 (June 1997):
                                                                     1491–1504.
   See also ALL HALLOWS’ DAY/ALL HALLOWS’ EVE.

                                                                  Halo Nurses    A program founded in 1994 by
Hallowmas      See ALL SAINTS’ DAY.                               Eileen Machan, a former oncology nurse at Akron


                                                            133
134 hanging

General Medical Center in Ohio. She felt that she        women, it was the third most common method
was unable to devote sufficient time listening to her     (16.7 percent) after firearms (37.2 percent) and poi-
patients’ concerns because she was busy with other       soning (30.6 percent).
nursing duties. To help with this need, she decided         See also AUTOEROTIC DEATHS; SUICIDE.
to call on a pool of retired nurses, soon to be known
as “Halo Nurses.” Halo Nurses help patients and
families alleviate anxiety associated with hospital-     hara-kiri A ritualistic suicide involving self-
ization, plus deal with end of life issues. These        disembowelment on a sword; once practiced in
nurses sit, listen and encourage patients, support       Japan but declared illegal in 1868. The abdomen
the family (or caregiver), and assist them in gaining    was cut horizontally, a vertical thrust was made, and
the skills they need to help their loved one and         a friend provided decapitation. The custom used to
themselves through their crisis, and generally pro-      be reserved for the nobility and military warriors. It
vide companionship and emotional support to              was generally commanded by the government to
patients. In most hospitals, Halo Nurses are retired     certain disgraced officials as a form of sanctioned
nurses who have been specifically trained in stress       punishment whereby the individual should die by
management using therapeutic listening, relaxation       his own hand rather than be beheaded.
techniques, and guided imagery.

                                                         hastening death        Term used in discussions of ter-
hanging      A method of execution where a 3 ⁄4- to 1-   minally ill patients who experience much pain that
inch rope (called a hangman’s noose) is put around       cannot be relieved and who may request from med-
a person’s neck and the person falls through a trap      ical staff assistance in hastening their deaths. Quill et
door built into a wooden frame or gallows. Until the     al. contend that “Terminal sedation and the volun-
1890s, hanging was the primary method of execu-          tary cessation of eating and drinking may be legally
tion used in the United States. Hanging is still         acceptable alternatives to PHYSICIAN-ASSISTED SUICIDE
allowed in Delaware and Washington, although             for the few patients whose suffering cannot be made
both have lethal injection as an alternative method      tolerable with standard palliative interventions.
of execution. The last public hanging in America         Physicians should not violate their fundamental val-
occurred on August 14, 1936, in Owensboro, Ken-          ues when faced with such patients but should make
tucky. At one time, attending a hanging was a way        patients aware of the full range of available alterna-
of standing with the community against the crimi-        tives to prolonged, intolerable distress.”
nal, a means of showing the seriousness with which           McNeil quotes Dr. Quill as explaining that the
one took crime and its consequences. But public          starving body releases endorphins as it breaks down
revulsion of the spectacle had started brewing.          its own tissue for energy “and it’s not unpleasant.”
Then, when reporters from around the country                 In some of these situations, doctors may admin-
attended and later wrote about what they called          ister pain medication with the intention of relieving
the “carnival in Owensboro,” an embarrassed state        pain and with the possible unintended secondary
of Kentucky abolished public executions. Other           effect of hastening death. Such measures allow a
states soon followed that policy.                        more passive role in hastening death than the more
   Hanging is also a common method of suicide.           active ASSISTED SUICIDE. In a survey of Tennessee
According to data released by the National Center        physicians, regardless of their overall positions on
for Health Statistics, a division of the Centers for     EUTHANASIA and physician-assisted suicide, 44 per-
Disease Control and Prevention, in the year 2000         cent agreed and 34 percent disagreed that hastening
hanging, strangulation, and suffocation was the sec-     death should be restricted to adult patients. In a
ondmost common method of suicide, with 19.4 per-         2003 Oregon study, 102 of the 429 hospice care
cent of all suicides that year in that category. Among   nurses who were mailed questionnaires replied that
men, it was the secondmost common method (20.0           they had cared for at least one patient who chose to
percent) after firearms (61.2 percent). Among            hasten death by declining food or fluids. Some
                                                                            Hawaiian Native burial customs 135

physicians oppose giving patients the option of star-          ing eulogies, and sometimes “hacking” away their
vation because they fear that many doctors are                 hair on the sides of their head, knocking out a
incompetent at recognizing clinical depression, as             tooth, or scarring their skin with burning twigs—all
opposed to gloom, in the dying.                                with the intention of showing that even though the
   See also TERMINAL SEDATION.                                 pain was great, their grief was greater. She writes,
                                                               “Corpses were treated with respectful ceremony in
Essinger, Douglas. “Attitudes of Tennessee Physicians          preparation for interment, as it was believed the
   toward Euthanasia and Assisted Death.” Southern Med-        bones, the iwi, of the dead held great mana, divine
   ical Journal 96, no. 5 (2003): 427–435.                     power, that contributed to the natural order of life,
McNeil, Donald G., Jr. “Reports on Fasting Add to              and could benefit whomever possessed his ances-
   Euthanasia Debate.” International Herald Tribune,           tor’s bones.”
   August 1, 2003.                                                 In 1825 William Ellis, a mate on Captain James
Quill, Timothy E., et al. “The Debate over Physician-          Cook’s voyage among the islands, described the
   Assisted Suicide: Empirical Data and Convergent Views.”     importance of bones in his journal: “These bones
   Annals of Internal Medicine 128 (April 1, 1998): 552–558.   were either bound up with cinet, wrapped in cloth,
                                                               and deposited in temples for adoration, or distrib-
                                                               uted among the immediate relatives, who, during
hauntings      Repeated materialization of unex-               their lives, always carried them wherever they
plained sensory phenomena, such as sounds or                   went.”
smells or HALLUCINATIONS, attached to a particular                 How and where the body or, sometimes, only
place. Most such incidences involve noises, such as            the bones were buried varied from island to island
footfalls or rustlings or animal sounds, or odors such         and among social rankings. Kings were likely to
as that of flowers or perfume or burned wood, or                have arm or leg bones preserved and hidden in
tactile sensations, such as a cooling breeze or prick-         caves—always under secrecy of nightfall. Com-
ing of the skin. Hauntings may be periodic or con-             moners might be buried in sand dunes, in the
tinual, during a short time period or spread out over          ground near their homes, or in burial caves. Corpses
centuries. No scientific explanations exist for why or          might be buried in a supine position; they might be
how hauntings occur, but the popular belief is that            bent into a fetal-type position, as described by the
most hauntings involve ghosts of the dead. Stories             historian Malo: “A rope was attached to the joints of
of long-time hauntings proliferate in Great Britain            the legs then being passed about the neck, was
and in older American cities such as Savannah,                 drawn taut until the knees touched the chest. The
Georgia.                                                       body was then done up in a rounded shape and at
                                                               once closely wrapped in tapa and made ready for
                                                               burial.”
Hawaiian Native burial customs            Death has                Although burial caves have been found on every
always been an important event for Native Hawai-               Hawaiian island, many had already been looted—
ians, with burial of the remains—often in secret               sometimes by major museums and treasure-hunters
caves—treated respectfully, as the Hawaiians have              from around the world—before the proper author-
traditionally revered the bones of the dead, to them           ities could preserve and account for their contents.
a symbol of immortality. Bones were the last impor-            But since passage of the NATIVE AMERICAN GRAVE
tant place in which the soul existed.                          PROTECTION AND REPATRIATION ACT, Native Hawai-
    Hiding the bones was very important, especially            ians have been able to arrange the return of many
for royals and chieftains, in an attempt to keep their         ancestral remains and re-inter their bones “at night
spirit from being stolen. When the person died at              and under strict secrecy.”
home, someone had to guard the body until the
proper person came to perform a ritual cleansing.              Fullard-Leo, Betty. “Sacred Burial Practices.” Coffee Times.
    Fullard-Leo explains that bereaved relatives and              Available online. URL: http://www.coffeetimes.com/
friends would mourn by weeping profusely, chant-                  feb98.htm. Posted February 1998.
136 headstone

headstone A stone that is used to mark a grave,               earliest American funerals utilized family and
usually made of bronze, marble, granite, or lime-             friends acting as pallbearers to carry the coffin to the
stone; so named from its customary placing at the             graveyard. Then simple wagons were used, and
head of the buried corpse. In some eras, both a               later more ornately carved wooden boxes were used
headstone and footstone were common.                          and pulled by horses. Traditionally, black hearses
   See also GRAVE MARKER; GRAVESTONE; SYMBOLISM               have been used for adults and white for children.
ON GRAVESTONES.                                               When motor vehicles became popular, hearses nat-
                                                              urally became motorized, although in the begin-
                                                              ning many people would not allow their deceased
health care proxy A medical power of attorney                 loved ones to be carried in the “motorcars,” so
by which the patient appoints a trusted person to             funeral homes had to maintain both horse-drawn
make decisions about his or her medical care if he or         and motorized hearses for a period of time.
she cannot make those decisions. It may also be
called a DURABLE POWER OF ATTORNEY. In many cases,
the spouse or other next-of-kin would automatically           heaven In many religions, heaven is seen as the
be able to make these decisions, but in situations            home of God, angels, and the souls of those who
where a person prefers a non-family member to do              have gained salvation or of the just. Also called par-
this, a health care proxy is the answer. Some experts         adise, Nirvana, the promised land, Eden, and
who have dealt with end-of-life issues recommend              Shangri-la. Most see heaven as a place in which the
the designation of a health care proxy who clearly            soul will live with God “bathed in perfect love and
knows and respects one’s wishes, rather than relying          peace.” It has also been described as “the place
on a LIVING WILL. However, others caution that even           where nothing ever goes wrong.” Although Jews,
health care proxies have potential for problems.              Christians, and Muslims may envision the details
Talan writes, “Increasingly, end-of-life cases are            differently, they all agree that it is the home of one
being decided in courtrooms . . . nationwide there            God, a perfect place where the those who die here
have been about 10,000 trial court decisions, most of         on Earth go to live forever. According to a Newsweek
them health care proxy disputes. About 60 to 70               poll, 76 percent of Americans believe in heaven,
cases have resulted in appellate court decisions since        and, of those, 71 percent think it is an “actual
the late ’70s.”                                               place,” but beyond that different views appear.
   Watstein cautions that a health care proxy also            “Nineteen percent think heaven looks like a garden,
“gives the person named visitation rights in the hos-         13 percent say it looks like a city—and 17 percent
pital and access to the patient’s medical records.            don’t know.” Most theologians will say that heaven
People are generally advised to sign an ADVANCE               is symbolic, but Miller finds that most people con-
DIRECTIVE in conjunction with a health care proxy as          tinue to think of heaven in terms of what they
the best guarantee of realizing their wishes for treat-       want. “That’s why dog-lovers think they will be
ment under particular circumstances.”                         reunited with their pets in heaven, and the poor
                                                              think of heaven as a place where they’ll never have
Talan, Jamie. “When Death Needs a Plan.” Newsday (New         to work.”
   York, N.Y.), March 11, 2003.                                   See also AFTERLIFE.
Watstein, Sarah Barbara, and Stephen Stratton. “Health
   Care Proxy,” in The Encyclopedia of HIV and AIDS, Second   Miller, Lisa. “Why We Need Heaven.” Newsweek. 12
   Edition. New York: Facts On File, 2003.                      August 2002: 43–51.



hearse    A vehicle for carrying a coffin to a church          heirlooms Material possessions that have been in
or a cemetery; also called a funeral coach or funeral         a family for multiple generations. Attorneys who
service vehicle. Today’s hearse is usually a black lim-       deal with WILLs and other end-of-life issues note
ousine looking much like any other limousine. The             that competition for family heirlooms and memen-
                                                                                   Hinduism and death 137

tos can strain good will—sometimes more than bat-        heroic measures A term used by patients and
tles over money.                                         providers to characterize a number of high technol-
                                                         ogy medical interventions that may be applied, usu-
                                                         ally regardless of a patient’s condition. Often that
hell   The underworld; for some religions, the oppo-     may involve significant discomfort and expense to
site AFTERLIFE destination from HEAVEN. Christians       the patient. Depending on the condition of the
believe it to be the abode of Satan and the forces of    patient and the circumstances, these measures may
evil, where sinners (or those who have not accepted      include cardiopulmonary resuscitation (CPR), res-
Christ as their savior) suffer eternal punishment—       pirators, kidney dialysis, organ transplantation,
the home of the damned. In the early days of Amer-       extensive surgical procedures, electric shock,
ica, preachers exhorted their listeners to follow the    chemotherapy, and intravenous nourishment or
path of righteousness or be forever damned in hell;      feeding tubes. In many instances, these measures
it was the primary message of the day. But historians    are not “heroic,” but do heal and restore the patient
say that the threat of hell as a final resting place is   to health. But in some situations, technology may
beginning to fade among today’s preachers; instead,      be applied thoughtlessly, lengthening the dying
the emphasis is on the positive, on how high a place     process while adding suffering and expense for the
one will reach in heaven. When people do think of        patient and family.
hell, they likely envision either fire or darkness.
    See also HADES.
                                                         high brain death The loss of brain functions that
Woodward, Kenneth. “Why We Need Hell, Too.”              define a person—decision making, passions, and
  Newsweek, 12 August 2002: 52.                          reason.
                                                            See also BRAIN DEATH.
Hemlock Society In July 2003 this group
changed its name to End-of-Life Choices. A non-          Hinduism and death With nearly 820 million Hin-
profit association of people who support the right of     dus, mostly in India and Nepal, Hinduism is the
dying patients to choose suicide if they wish, the       world’s third-largest religion, although it is consid-
Hemlock Society was founded in 1980 by Derek             ered more a “life code” than a structured religion. A
Humphry, whose book Final Exit stirred up contro-        Hindu looks at death as “the great journey.” The
versy by evaluating various methods of suicide.          Hindu belief in reincarnation—that each of us is born
Today the society has more than 30,000 members in        again and again in a life cycle—shapes both their phi-
about 70 chapters and community groups around            losophy of death and their funeral ceremonies.
the country. Their goal is to legalize PHYSICIAN-        Because they expect to be born again, Hindus do not
ASSISTED SUICIDE. The original name was taken from
                                                         look upon death as despondently as others; instead,
a poisonous plant. Hemlock is believed to be the         it is a most exalted human experience, with the qual-
poison drunk by Socrates in 329 B.C.E. Information:      ity of death as important as one’s quality of life, so it
End-of-Life Choices                                      is important to die peacefully when one’s time comes.
P.O. Box 101810                                          Traditionally, that has meant that Hindus most often
Denver, CO 80250–1810                                    die at home among the comfort of loved ones. Even
(800) 247–7421 (toll-free)                               when a Hindu must die in a hospital, the family
hemlock@hemlock.org                                      keeps the traditional vigil until the soul departs while
http://www.hemlock.org or                                reading scripture, praying, and singing hymns—even
 http://www.endoflifechoices.org                          if against hospital policy.

                                                                  Funeral Rituals and Mourning
hereafter   Life after death.                            Once death occurs, an elaborate set of rituals is con-
   See also AFTERLIFE.                                   ducted, mostly by relatives, to ensure a proper
138 Hispanic Americans/Latinos and death

rebirth. These funeral rituals represent celebration      during the past year offer fruit, bread, beaten rice,
more than the remembrance of other religions and          curd, and money to those participating in the pro-
cultures. The body is immediately laid on the floor,       cession, including the cows.
with a small flame lit near it. Hindus believe that at        Hindus believe that autopsies are disturbing to
death, the soul leaves the body but continues to          the still aware soul, and thus should be avoided
inhabit the home due to its attachment to family          unless required by law. They also do not allow
and friends, and now needs a resting place—thus           embalming unless it is required by law.
the flame becomes that resting place.                         See also BUDDHISM AND DEATH.
    Rituals continue for 12 days and include prepa-
ration of the body by the eldest son or some other        Adhopia, Ajit. “Hindus Prepare for Death from Child-
designated person. In India, the bathed and dressed          hood.” The Toronto Star, September 2, 2000.
body is carried on a stretcher to the FUNERAL PYRE        Crawford, S. Cromwell. Dilemmas of Life and Death: Hindu
(ideally within 24 hours of death), where the eldest         Ethics in North American Context. Albany: State Univer-
son lights the fire. In the United States, the body is        sity of New York Press, 1995.
usually carried by ambulance or hearse to a crema-
torium, where the eldest son will push the button
on the crematory to symbolize the lighting of the         Hispanic Americans/Latinos and death Even
funeral pyre. Only the men attend cremations.             though Hispanic Americans are generally lumped
Infants are not cremated, but are buried.                 together for medical and demographic studies, their
    Following cremation, the CREMAINS are collected       roots spread out to several different countries and
and then carried or sent to India for depositing in       cultures, and encompass all races. The major coun-
the holy Ganges River. In the United States and           tries of origin, according to a Strategy Research
Canada, they may be placed in an auspicious river         Corp. study in 2000, are Mexico (58.6 percent),
or the ocean, along with garlands.                        Puerto Rico (7.3 percent), Cuba (6.6 percent), El
    On the 10th day following death, after a night of     Salvador (5 percent), Dominican Republic (4.2 per-
prayer, the flame that is holding the soul is carried      cent), Colombia (3 percent), Guatemala (2.3 per-
out to sea, as a sign to the soul to break all attach-    cent), and Argentina (1.5 percent). From these
ments with its former life and begin its journey for-     origins have come specific beliefs and traditions con-
ward to a new one.                                        cerning death, dying, and end-of-life issues.
    On the 31st day following death, a memorial               Religious beliefs or practices about the end of life
service will be held, which includes the purification      are common among racial and ethnic groups, and
of the home by a priest (but this may also be done        for many Hispanics, according to The Hastings Report,
by some on the 11th day following cremation).             “Death is determined by God’s will, and suffering is
    Gaijatra is an annual Nepalese Hindu ritual in        an integral part of the process. Family members and
which the children and grandchildren of people who        friends offer prayers at the bedside, at a home altar,
have died over the past year participate, in the hope     and in church. Candles may be kept burning
of aiding the souls of the dead to find their way to       twenty-four hours a day as a means of continuous
heaven. The festival, called the “parade of cows,”        worship. Clergy and lay visitors are common in the
lasts for a week during August/September. Every           hospital and at home.”
family who has lost one relative during the past year         In a study published in the Journal of the American
must participate in a procession through the streets of   Medical Association, researchers reported that elderly
Kathmandu leading a cow. If a cow is unavailable,         Mexican Americans were less likely than elderly
then a young boy dressed as a cow is considered a fair    African Americans and European Americans to
substitute. In Hinduism, a cow is regarded as the most    believe that a patient should be told of a terminal
venerated among all the domestic animals. Hindus          prognosis and less likely to believe that the patient
believe that the deceased during their journey to         should make decisions about the use of life-support
heaven cross a legendary river by holding onto the        technology. Mexican Americans were said to be
tail of a cow. Family members of those who died           more likely than the other two groups to believe
                                                              Hispanic Americans/Latinos and death 139

that the family and not the patient should make          ancient values about the importance of family
end of life decisions.                                   involvement at the end of life.
                                                            According to the Hastings Center Report, “Many
           Cultural Beliefs and Traditions               Mexican Americans and other Hispanics also adhere
End-of-life experts have stated that in some His-        to a family-centered model of medical decision-
panic groups, there’s a tendency to equate open dis-     making. One survey found that 45 percent of eld-
cussion of death with loss of hope. Families may         erly Mexican Americans believed that the family,
want to shield their loved one from serious diag-        not the patient, should be the primary decision-
noses. A California study found that first-generation     maker in terminal care. Mexican-American men
immigrants regarded talking about advance plan-          are often expected to provide for and be in charge of
ning as taboo because this would be a bad omen,          their families.”
but that second- and third-generation residents             In a May 1997 report, The Quest to Die with Dignity,
were much more open about the topic. In a 1995           issued by American Health Decisions of Appleton,
study of elderly Los Angeles residents, 65 percent of    Wisconsin, responses for the Hispanic group showed
Mexican Americans said that they would not want          they are
to be told if they had a fatal illness.
   Perhaps nowhere is the ignoring of impending          • split in their trust of physicians;
death more evident than in the hospice arena. In         • more comfortable with discussions about death;
2000 only 2 percent of all hospice patients in the       • more likely to agree that physicians should initi-
United States were Hispanic. But much of this hos-         ate end-of-life discussions;
pice non-use has been said to arise from Hispanics
                                                         • most likely to support mandatory living wills;
thinking that hospice is an institution that violates
the tradition of caring for dying relatives at home,     • always agree that age should never be a factor in
and Latino/Hispanic elders often believe that if the       making end-of-life decisions;
family cannot provide care, they are not fulfilling       • more likely to agree that quality of life is impor-
their responsibility. In 2002 a Boca Raton hospice         tant in making end-of-life decisions; and
received grants of more than $1.1 million to help        • likely to support physician-assisted suicide.
break down misconceptions among South Florida
Hispanics about end-of-life hospice care.                Organ donation is an end-of-life issue often misun-
   Various studies have shown that the deep sense        derstood by Hispanic Americans, according to Frates
of being part of a family network strongly influ-         and Garcia Bohrer, who note that the low rate of
ences end-of-life decisions among Hispanics.             organ donation among Hispanics is of increasing
Among these findings: The valuing of family con-          concern to the transplant community at a time
siderations over individual or community needs is        when the Hispanic population is growing rapidly,
nearly universal. Relatives of Hispanics also partic-    especially in southern California. When OneLegacy,
ipate in the physical and spiritual care of the dying,   the nation’s largest organ procurement organiza-
and many travel considerable distances to do this.       tion, commissioned a series of in-depth individual
Hispanic family members are nearly always willing        interviews with Spanish language-dominant His-
to provide personal care, but they may be unwilling      panics to identify barriers and motivators to organ
to provide technical care unless extensive teaching      and tissue donation, they found “a common reti-
is provided. In some Hispanic families, pregnant         cence to speak of or make plans for either their own
women do not provide personal care or attend the         or a family member’s death and lacked knowledge
funeral. Children sometimes are shielded from            of procedures surrounding donation (whether con-
involvement in care of the dying, but they also may      senting or being a donor themselves).” Some
have great responsibility. According to one hospice      respondents did not understand that organ dona-
chaplain, many Latinos do not know that hospice          tion takes place after death, expressing fears that
care provides whatever is needed so that people can      declaring themselves donors would put them at risk
die at home among loved ones, keeping alive              of being allowed to die so that their organs could be
140 holidays and other “marker dates”

recovered. Other attitudinal barriers included the           a time to remember ancestors. Koreans eat food
wish to die with all body parts intact and reluctance        with family and friends, plus honor the dead by
to have another person’s organ in their bodies.              going to graveyards and taking food for the
                                                             deceased.
             Leading Causes of Death
According to the National Women’s Health Infor-
mation Center, the four leading causes of death              home burial With the typical cost of a funeral
among Hispanic/Latina women are the same as for              climbing to between $6,000 and $10,000, many
African-American women: heart disease, cancer,               American families are retreating to a simpler time
stroke, and diabetes. Among Hispanic/Latina                  when families and the community handled their
women, mortality rates from several diseases—                burial needs without the assistance of professional
including stroke; chronic obstructive pulmonary              funeral directors. For some, do-it-yourself funerals
disease; and cancers of the respiratory system and           or burials are chosen more for the personal aspect.
breasts—are lower than those of Caucasian women.             Carlson explains that families who have handled
Mortality rates from HIV/AIDS and homicide, how-             death arrangements privately share a feeling of spir-
ever, are significantly higher for Hispanic/Latina           itual and emotional fulfillment. “For many, it has
women than Caucasian women.                                  facilitated the grieving process by keeping the fam-
   In the United States, Hispanic youth are victims          ily involved. Some have felt they were better able to
of homicide at less than half the rate of African-           ‘let go’ when the time came.”
American youth (23.7 per 100,000 compared to                     Home burials do require an examination of local
61.2 per 100,000), but nearly three times the rate of        zoning ordinances, but according to Carlson, for
non-Hispanic whites (8.2 per 100,000).                       those with land in rural or semi-rural areas, home
                                                             burials usually are possible. Where land is not avail-
Frates, J. and G. Garcia Bohrer. “Hispanic Perceptions of    able, or where zoning will not allow home burials,
   Organ Donation.” Progress in Transplantation 12, no. 3    people are compromising by handling the funeral
   (September 2002): 169–175.                                services themselves and some or all of the prepara-
LaMendola, Bob. “Hospice Targets Hispanics.” Sun-Sentinel,   tion, then opting for GREEN BURIALS in land set aside
   September 4, 2002.                                        for that purpose. In her book, Carlson has a state-
Hastings Center. “Race, Ethnicity, and Culture.” The Hast-   by-state overview of requirements for death certifi-
   ings Center Report 33, no. 2 (March 2003): 539+.          cates, transportation and disposition permits, burial,
                                                             and cremation, as well as medical schools for body
                                                             donation, location of crematories, and other infor-
holidays and other “marker dates”          See ANNIVER-      mation of help. Only six states place limits on fami-
SARY REACTION; CELEBRATION DAYS.                             lies who want to take charge of the process:
                                                             Connecticut, Indiana, Louisiana, Michigan, Nebraska,
                                                             and New York, according to an article in Mother
holidays of the dead     Rather than looking upon            Earth News.
death solely as the final page of life and therefore
something to keep one’s distance from, as many               Carlson, Lisa. Caring for the Dead. Hinesburg, Vt.: Upper
Americans view it today, some cultures see death as             Access Books, 1998.
the beginning of a new chapter in life, and thus a           Davis, Lisa. “A Tomb of One’s Own.” SF Weekly, December
life event to be embraced and celebrated. For                   11, 2002.
example, many Mexicans and Mexican Americans                 Kerkstra, Patrick. “Bringing the Dearly Departed Home: A
observe Día de los Muertos, the DAY OF THE DEAD,                Reborn Backyard Trend.” Philadelphia Inquirer, October
which celebrates life and the people who have                   26, 2002.
passed away. The Korean holiday Chusok also pays             Morgan, Ernest. Dealing Creatively with Death: A Manual of
tribute to the dead. Also known as Korean Thanks-               Death Education and Simple Burial, 14th Edition. Hines-
giving, Chusok falls in August or September and is              burg, Vt.: Upper Access Books, 2001.
                                                                                                homicide 141

Smith, Nancy. “Greener Ways to the Great Beyond.”            Examples of personal care and support services
  Mother Earth News. Available online. URL: http://www.   include: help with basic daily activities like getting
  motherearthnews.com/index.php?page=rec&1d=2052.         in and out of bed, dressing, bathing, eating, and
  Posted April 2003.                                      using the bathroom; help with light housekeeping,
                                                          laundry, shopping, and cooking.
                                                             It is important to note that “home care” is differ-
home health care      The need for home health care       ent from HOSPICE care, which also usually takes place
has grown along with the improvement of medical           in the home. Hospice care focuses on the compre-
science and technology. Many treatments that could        hensive treatment of dying patients, while home
once be done only in a hospital can now be done at        care treats the physical symptoms of people, many of
home. Also, home health care is usually less expen-       whom will recover from their illness. Those patients
sive and can often be as effective as care in a hospi-    receiving home health care for illnesses that later
tal or skilled nursing facility. And just as important,   become terminal may then qualify for hospice care.
most patients and their families prefer to stay at home
rather than be in the hospital or a nursing home.         Watstein, Sarah Barbara, and Stephen Stratton. “home
    Watstein cautions that home health care “can also       health care,” in The Encyclopedia of HIV and AIDS. New
be fragmented, erratic, poorly administered and             York: Facts On File, 2003.
supervised, and literally out of control. Successful
home care must carry into the home setting the team
approach that characterizes hospital care, in which       homicide Unlawful premeditated killing of a human
case the family and other caregivers must be part of      being. On an average day in the United States, 53
the team in a way that they are not in an institution.”   persons die from homicide. Despite a decline in
    Because most home health care is temporary and        homicide numbers and rates, the homicide rates for
part-time, caregivers need to learn how to identify       teenagers and young adults (ages 15 to 24) remain
and care for possible problems, like confusion or         high and are the second leading cause of death of
shortness of breath. When someone receives home           these age groups, according to the National Center
health care, the home health staff teaches caregivers     for Health Statistics (NCHS). The Indiana Depart-
about medication, wound care, therapy, and man-           ment of Public Health has stated that “public health
aging stress.                                             professionals must determine what and why certain
    Medicare Parts A and B cover part-time skilled        social and environmental factors place people at risk
nursing care, physical therapy, home health aide          for violent crimes endangering health. These factors
services, medical social services, durable medical        include poverty, discrimination, lack of increased
equipment (such as wheelchairs, hospital beds, oxy-       education, and lack of employment opportunities.”
gen, and walkers) and medical supplies, and other            In relation to victims, studies show that elderly
services, as long as certain conditions are met.          persons, females, and children continue to be the
    These services are given by a variety of skilled      main targets of both physical and sexual assaults,
health care professionals at home. The home health        which are frequently carried out by individuals they
staff provides and helps coordinate the care and/or       know.
therapy order by the doctor. Along with the doctor,          According to the U.S. Department of Justice, from
home health staff create a written care plan. The         1976 to 1999, 76.3 percent of homicide victims
home health staff keeps the doctor up-to-date on          were males, and 23.7 percent were women. During
how the patient is doing and updates the care plan        that same period, males committed 87.7 percent of
as needed.                                                homicides and women committed 12.3 percent of
    Examples of skilled home health services include:     homicides. Males are three times more likely to be
wound care for pressure sores or a surgical wound;        killed and eight times more likely to kill than
respiratory care, like oxygen or a nebulizer; patient     females are. Most homicide offenders are between
and caregiver education; intravenous or nutrition         the ages of 14 and 24. In 1999, there were 16,889
therapy; injections.                                      homicides in the United States.
142 horsemen of the Apocalypse

   In the United States, African-American and His-         hospices now contract with nursing homes and hos-
panic youth are victims of homicide at much higher         pitals to provide hospice-type care for dying patients
rates than whites. In 1999, African Americans aged         in the institution’s facilities.
20 to 24 years had a homicide rate (61.2 per                   Basically, hospice provides health care and sup-
100,000) that was more than twice the rate of their        port services to individuals and their families when
Hispanic counterparts (23.7 per 100,000) and nearly        they are facing life threatening illnesses. Hospice
eight times the rate of their white counterparts (8.2      workers consult with patients and their medical
per 100,000). In the Native American Indian/               teams on ways to experience the end of life with
Alaska Native community, it is estimated that 75           dignity. Hospice care dispenses with curative care
percent of female Native American Indian and               and maximizes COMFORT CARE (reducing or sus-
Alaska Native homicide victims are killed by some-         pending pain and other troubling symptoms, rather
one they know. Intimate partner violence is on the         than treating with the intent of curing) for the
rise within this population.                               whole person, including medical, emotional, social,
                                                           psychological, and spiritual measures to maximize
                                                           not only the physical comfort of the dying patient,
horsemen of the Apocalypse       Allegorical figures        but also his or her dignity and emotional well-being.
in the Bible’s New Testament Book of Revelation.           It is for all age groups, including children, adults,
The rider on the white horse has many interpreta-          and the elderly during their final stages of life.
tions—one is that he represents Christ, another,               Officially, hospice care is characterized by the fol-
war, and yet another, conquest; the rider on the red       lowing features: 1) the patient’s disease is terminal
horse is war (or slaughter); on the black horse is         (approximately six months or less until death) and
famine; and on the pale horse, death.                      no aggressive efforts to prolong life are used; 2) the
                                                           patient and family are treated as an integrated unit;
                                                           3) services are provided by an interdisciplinary team
hospice      A concept of care originating in England      with in-patient and home care components coordi-
with the purpose of easing the dying process for           nated; 4) hospice care services are available 24
terminally ill patients. In Europe, especially in Great    hours per day, seven days per week; and 5) pain
Britain, the term hospice is also given to the resi-       control and psychological well-being are prominent
dential facility itself, where such care is usually pro-   goals. Hospice promises compassionate care and
vided. Typically, Ammer writes, the European               improvement (over existing medical practices) in
hospice is “in a pastoral setting where the terminally     quality of life for the dying person and the family.
ill may live out their days in peaceful surroundings.      Much of the enthusiasm for hospice care came from
Such hospices are based on the medieval ‘hospital-         the assumption that it would be less costly while still
ity houses’ from which the term is derived, shelters       being effective. Thus, in 1982, Congress passed a
maintained by religious orders that took in                bill to cover hospice under Medicare. To qualify for
strangers, travelers and the indigent sick.”               Medicare coverage, hospices are required to include
    In the United States, while the care itself is based   nursing care, medical social services, physician serv-
on the same model, the location of that care is dia-       ices, counseling, short-term in-patient care, medical
metrically opposite. In-patient care, whether pro-         appliances and supplies, homemaker/home health
vided by a licensed hospital, licensed skilled nursing     aide services, and rehabilitation therapy.
facility, or the hospice’s own in-patient facility, is
kept to a minimum. A major goal of American hos-                            History of Hospice
pice care is to enable the patient to die at home in       Although the hospice concept dates to ancient times,
the comfort of his or her own surroundings without         neither the current British nor American hospice
being separated from family and friends, which is          movements began until the 1960s. The name hos-
accomplished by providing regular home visits by           pice was first applied to the care of dying patients by
nurses and physicians. When a patient is unable to         Mme. Jeanne Garnier who founded the Dames de
be cared for in his or her home, some hospices have        Calaire in Lyon, France, in 1842. The name was next
facilities in which they can house the patient. Many       introduced by the Irish Sisters of Charity when they
                                                                                                 hospice 143

opened Our Lady’s Hospice in Dublin in 1879 and St.       • Two to 5 percent of hospice patients improve and
Joseph’s Hospice in the Hackney borough of Greater          go off hospice care.
London (1905). At that time, a hospice was a reli-        • Hospice use is more common in some demographic
gious center dedicated to caring for seriously ill and      groups than others. Some 20 percent of white ben-
dying patients. The first use of hospice as specialized      eficiaries who died in 1998 elected hospice care,
comfort care for dying patients was in 1967 by physi-       compared to 15 percent of black beneficiaries who
cian Dame Cicely Saunders, who combined the                 died that year. Hospice use has grown at a fairly
medieval notion of service to the dying with the            consistent rate across most demographic groups, so
modern science of pain management, symptom                  users today are similar to those in 1992. The dis-
control, and grief counseling, and founded the first         tribution of enrollees by race has remained
modern hospice, St. Christopher’s Hospice, in a res-        steady—89 percent are white. The proportion who
idential suburb of London.                                  are women has climbed to 54 percent from 50 per-
   Saunders then introduced the idea of specialized         cent. But use of services by people age 80-plus grew
care for the dying to the United States during a 1963       faster than that of younger groups. Nearly half (47
visit to Yale University. Her lecture, given to medical     percent) of Medicare hospice enrollees were age
students, nurses, social workers, and chaplains about       80-plus in 1998, up from 35 percent in 1992.
the concept of holistic hospice care, included photos
of terminally ill cancer patients and their families,          Hospice Service Providers and Associations
showing the dramatic differences before and after         Between 1984 and 2002, the number of hospice
the symptom control care. In 1965, Florence Wald,         programs certified by Medicare increased from 31 to
then dean of the Yale School of Nursing, invited          2,265. The Hospice Association of America notes
Saunders to become a visiting faculty member of the       that there are also an estimated 200 volunteer hos-
school for the spring term. And in 1968, Wald took        pices in the United States. Less is known about the
a sabbatical from Yale to work at St. Christopher’s       hospices that do not participate in the Medicare or
and learn all she could about hospice.                    Medicaid programs, as the rules and regulations for
   The first hospice in the United States, the Con-        licensure vary by state.
necticut Hospice, began providing services in March           For full contact information on the major hospice
1974. It was funded by the National Cancer Institute      associations in the United States, plus the major
for its first three years.                                 hospice providers, see Appendix V.
           Statistics and Demographics                                  Paying for Hospice Care
• In 2002 more than 885,000 Americans living              Insurance coverage for hospice care is available
  with a life-limiting illness were served by the         through Medicare, Medicaid, and most private insur-
  nation’s hospice providers, according to data col-      ance plans. The National Hospice and Palliative Care
  lected by the National Hospice and Palliative Care      Organization (NHPCO) reports that in 2000 at the
  Organization from its provider members. This            time of admission, approximately 79 percent of hos-
  represents an increase of almost 15 percent over        pice patients claimed Medicare as their payment
  the estimated 775,000 patients served in 2001.          source, 13 percent private insurance, 5 percent Med-
  The median, or average, length of stay in 2002          icaid, 3 percent alternative sources, and 1 percent
  also rose to 26 days, up from 20.5 days in 2001;        self-pay.
  the mean rose from 48 to 51 days.
• Although more beneficiaries are choosing hos-            1. Medicare Medicare is the largest payor for hos-
  pice care, many are doing so closer to the time of         pice services. Medicare regulations require that
  death, according to the General Accounting                 most of the patient’s care be provided in the
  Office. Their numbers showed that the average               home setting, with short stays in an in-patient
  period of hospice use declined to 59 days in 1998          facility. Those who qualify for hospice care under
  from 74 in 1992. Half of hospice users receive             Medicare can get medical and support services,
  care for 19 or fewer days and care for one week            including nursing care, medical social services,
  or less is common.                                         doctor services, counseling, medical equipment
144 hospice

  (such as wheelchairs or walkers), medical sup-             Columbia provide hospice coverage to their
  plies (such as bandages and catheters), drugs for          Medicaid beneficiaries, although that number
  symptom control and pain relief, and home-                 does change from year to year.
  maker services. To be eligible to receive the           3. Private Insurance Most private insurance com-
  Medicare hospice benefit, a patient must have               panies include hospice care as a benefit; some
  two physicians certify that, if the patient’s ter-         also pay for general home care. Hospice is also
  minal illness were to run its usual course, the            covered by most HMOs and other managed care
  patient would have a life expectancy of six                organizations. Military personnel and their
  months or less. The patient must also sign a               dependents are covered for hospice under
  statement choosing hospice care instead of rou-            CHAMPUS (Civilian Health and Medical Pro-
  tine Medicare-covered benefits for the terminal             gram for the Uniformed Services).
  illness; and must receive care from a Medicare-
  approved hospice program. Medicare will still              According to the Hospice Association of Amer-
  pay for covered benefits for any health problems         ica, hospices continue to rely heavily on grants
  that are not related to the terminal illness.           and community support to fund unreimbursed
      Medicare for hospice care will not pay for          care and hospice services for patients with little or
  treatment to cure a terminal illness; care from a       no insurance.
  hospice or other provider not set up by the origi-
  nally approved hospice; room and board.                                 Problems with Hospice
  Medicare pays the hospice for hospice care. The         A report released in January 2003 by the LAST ACTS
  patient pays no more than $5 for each prescrip-         organization in Washington, D.C., found that states
  tion drug and other similar products. (The hospice      are doing little to encourage terminally ill patients to
  can charge up to $5 for each prescription for out-      seek hospice care, or to do so earlier in their illness
  patient drugs or other similar products for pain        to take the greatest advantage of hospice benefits.
  relief and symptom control.) The patient also pays         In their brief, “Hospice Care—Part II: Barriers to
  5 percent of the Medicare payment amount for            Hospice Care and Some Proposed Policy Solutions,”
  inpatient RESPITE CARE. For example, if Medicare        Community-State Partnerships (C-SP) discuss
  pays $100 per day for inpatient respite care, the       numerous problems and possible solutions with the
  patient will pay $5 per day. A patient can stay in      current state of hospice care. Among the problems
  a Medicare-approved hospital or nursing home            they cite:
  up to five days each time he or she gets respite
  care. There is no limit to the number of times one      • More than 80 percent of people eligible for
  can get respite care. The amount the patient pays         Medicare do not know it offers a hospice benefit.
  for respite care can change each year.
                                                          • Those who eventually receive hospice usually
      A patient can receive hospice care as long as
                                                            suffer too long from uncontrolled pain and symp-
  his or her doctor certifies that he or she is termi-
                                                            toms before being referred to hospice.
  nally ill and probably has less than six months to
  live. If the illness goes into remission, the patient   • The average Medicare hospice patient’s length of
  would go off hospice at the end of that period of         stay has decreased from 70 days at the Medicare
  care. Then, should the patient’s disease state once       Hospice Benefit’s (MHB) inception in 1983 to
  again become eligible for hospice care, the               about 36 days in 2000, with more than half of
  patient’s doctor would recertify that he or she is        hospice patients staying less than 25 days and
  terminally ill.                                           more than one-quarter staying less than a week.
2. Medicaid Medicaid is designed to help public           • Since 1998, nearly one-and-a-half times as many
   aid recipients and people whose incomes are              hospices have been going out of business annu-
   higher than public aid eligibility limits, but who       ally than opening their doors.
   meet other criteria and cannot pay for medical         • The MHB pays for hospice services for people with
   services. Currently, 43 states and the District of       terminal illnesses but limits eligibility to those with
                                                                                             hospital care 145

  prognoses of six months or less. In general, this      further its attempts to guarantee access to all dying
  makes hospice more accessible to patients dying of     Americans. These include:
  cancer, but less accessible to many who have ter-
  minal illnesses with lengthier or less predictable     • Skilled nursing facilities, citing “overwhelming
  courses, such as AIDS, Alzheimer’s disease, and          support among consumers for the rights of ter-
  progressive, fatal organ disease.                        minally ill residents to remain in these facilities
• Nursing home residents at the end of life some-          and for the role of hospices in helping residents
  times have a difficult time accessing hospice care        achieve that goal, according to the results of
  because of confusing and burdensome require-             recent focus group research.”
  ments surrounding hospice care delivered in            • Simultaneous care, which means “offering seri-
  long-term care facilities.                               ously ill patients the compassionate support of
                                                           hospice or palliative care while they are still pur-
  Community-State Partnerships proposes policy             suing ‘aggressive’ curative, disease-modifying, or
changes to improve access and financial viability,          even experimental treatments.”
some of which are:                                       • Intensive care, noting that “any dying patients end
                                                           up in the ICU after an unexpected event such as an
Rethink hospice reimbursement, such as making              accident or flare-up of a serious, chronic illness.”
  MHB’s per diem reflect true costs, paying a
  higher rate for the higher cost first and last days,    Ammer, Christine. “Hospice,” in The New A to Z of Women’s
  adopting a policy for those whose costs of care lie       Health, Fourth Edition. New York: Facts On File, 2000.
  outside the average, and reexamining the Med-          Beresford, Larry. “Hospice Trends.” Hospice Management
  icaid hospice expense benefit.                             Advisor, March, April, May 2003.
Reevaluate eligibility requirements, such as the         Centers for Medicare & Medicaid Services. Medicare Hospice
  requirement that hospice recipients forego any            Benefits. Available online. URL: http://www.medicare.
  curative treatment, even the “long-shot”                  gov/publications/pubs/pdf/02154.pdf. Revised July
  attempts to control cancer, for example. Because          2002.
  families want to be able to continue to take the       Last Acts Campaign. “Hospice Care—Part II: Barriers to
  chance that their relative may be that “one in a          Hospice Care and Some Proposed Policy Solutions.”
  hundred” whom a new treatment might help                  Available online, URL: http://www.lastacts.org/files/
  live longer, they will generally not elect hospice.       publications/hospice2.pdf. Downloaded July 16, 2004.
Educate physicians and beneficiaries, such as
  through Medicare funding seminars and contin-
  uing education courses to clarify hospice benefit       hospital care The use of hospitals for terminal care
  regulations and to publicize existing policies that    of acutely ill older persons has been questioned on
  few physicians know about, including their abil-       the grounds of cost and ethics. Enormous amounts
  ity to recertify hospice patients who survive          of public funds, through Medicare and Medicaid, are
  longer than expected. Better consumer informa-         spent annually on care for older adults hospitalized
  tion about all existing Medicare-funded end-of-        for terminal care. Even though hospitals may be the
  life care choices, including the MHB, could be         most appropriate place for acutely ill elderly, the
  provided to beneficiaries, 80 percent of whom           risks of hospitalization are high in terms of cost and
  are unaware of the MHB. Doctors and attorneys,         iatrogenic illness, such as hospital-based infections,
  who play an intimate role in end-of-life care          disorientation, and bed sores.
  planning, should be included.                             Although recent legislative and policy changes
                                                         toward skilled nursing facilities, hospice, and home
                  Future for Hospice                     health care have led to reduced use of hospital-
In a series of articles during 2003, Hospice Manage-     based services, the hospital remains a major compo-
ment Advisor, an industry newsletter, forecast several   nent of the health care system for the terminally ill,
areas where hospice is making inroads and could          especially the elderly. Older persons are hospitalized
146 hospitalization insurance

at a rate four times greater than the rate for younger         and laughing freely with others can be a power-
persons. The average length of stay for persons over           ful antidote to stress.”
65 years of age is 30 percent longer than for persons         • And noting how humor has helped him deal
between 45 and 65 years of age.                                with several personal losses, Klein adds, “Humor
   In their state-by-state report issued in January            will frequently rear its head during the strangest
2003, the LAST ACTS organization in Washington,                of times. It is nature’s way of giving us a perspec-
D.C., found that although the number of organized              tive on a situation and allowing us to rise above
palliative care programs in hospitals is increasing,           it. Humor helps us keep our balance when life
such programs are not yet the norm. Nor do a suf-              throws us a curveball.”
ficient number of hospitals offer pain management              • Humor helps the medical and police staffs who
programs and HOSPICE services.                                  must deal with death on a nearly daily basis. Boes
                                                                and Van Wormer explain, “Gallows humor,
                                                                which takes its name from the genre of jokes
hospitalization insurance Insurance that pays all               about a condemned man about to be hanged on
or part of a patient’s hospital expense. Also called            the gallows, proposes an illogical, incongruous
health insurance, health coverage, or simply hospi-             response to the most hopeless of situations and
talization. One national study found that, over a               offers the person a triumph of sorts. For example,
17-year follow-up period, adults who lacked health              when offered a last cigarette, the doomed man
insurance at the outset had a 25 percent greater                may say, ‘No thanks, I just quit yesterday.’ Or,
chance of dying than did those who had private                  while the inmate on death row is being weighed,
health insurance—health insurance being a key to                he asks, ‘Y’all starting a Weight Watchers pro-
having access to high-quality health care.                      gram around here?’ Gallows humor represents
    In another study (see SUPPORT) of patients hospi-           more of a broad philosophical attitude than a par-
talized with life-threatening medical conditions so             ticular repertoire of jokes; it is a way to maintain
severe that half of the patients were expected to die           sanity under insane circumstances.”
within six months, even with hospitalization insur-
ance, nearly a third of the families of those patients            In his essay, Sexton quotes a cardiologist as say-
lost all or most of their savings. Another 29 percent         ing, “Most people, if they understood the codes we
of the families reported losing their family’s major          mask it in, would probably be really offended by the
source of income.                                             kind of morbid humor that goes on between med-
                                                              ical staff. It’s not that we’re callous people, or evil,
“Care without Coverage: Too Little, Too Late.” Institute of   it’s just that we have to find some way of coping
   Medicine, Committee on the Consequences of Uninsur-        with these emotional events. Humor is one way
   ance, National Academy of Sciences, Washington, D.C.,      that we can do that.”
   May 2002. Available online. URL: http://www.nap.edu/
   openbook/0309083435/html. Downloaded July 16,              Klein, Allen. The Courage to Laugh: Humor, Hope, and Heal-
   2004.                                                         ing in the Face of Death and Dying. New York: Jeremy P.
                                                                 Tarcher, 1998.
                                                              Sexton, James. “The Semantics of Death and Dying:
humor and death As incongruous as it may                         Metaphor and Mortality.” ETC.: A Review of General
appear, humor plays an important role in the death               Semantics 54, no. 3 (1997): 333+.
arena—from several perspectives:                              Van Wormer, Katherine, and Mary Boes. “Humor in the
                                                                 Emergency Room: A Social Work Perspective.” Health
• Humor helps the grieving. Explaining that grief                and Social Work 22, no. 2 (May 1997): 87–93.
  leads to stressful changes within the body,                 Wooten, Patty. “Humor: An Antidote for Stress.” Holistic
  Wooten writes, “Finding humor in a situation                   Nursing Practice 10, no. 2 (January 1996): 49–56.
                                                                                                              I
imminent death        Used when death is close at             occur on-site for fear that the death would be
hand; often included in ADVANCE DIRECTIVES or LIV-            equated with neglect. Often to avoid potential legal,
ING WILLs to describe when certain treatment                  ethical, and medical complications facilities have
options may or may not be implemented. It is                  found it easier to send all dying patients out of the
important to note that the term is open to interpre-          facility.”
tation, and not all states define imminent death                  In his USA Today article, McMahon writes,
equally. Some states define it as the point when              “Many older inmates die in prison without any fam-
death assuredly will come within a few hours or               ily or friends to pay for a funeral or burial. As a
days, regardless of efforts to avoid it. Other states         result, corrections officials often become funeral
will include with “imminent death” any condition              directors, cemetery operators and grief counselors in
that may be terminal but for which death may not              addition to health care providers.”
come for some time. Another definition that is                    In its report, the Criminal Justice and Correc-
sometimes used: Two doctors agree that regardless             tions Council, Florida Corrections Commission,
of the application or withdrawal of medical treat-            notes that more inmates today are dying in prison
ment death is likely to occur within hours or days.           due to AIDS and the imposition of longer prison
Because the ability to predict imminent death is not          sentences. More than 2,500 inmates died of AIDS
always easy, it has lead to terminology such as “the          and other natural causes in 1997. Not all elderly or
terminal phase of a terminal illness.”                        terminally ill inmates are suitable for release. In
                                                              response to these conditions, some correctional sys-
                                                              tems have adopted a formal HOSPICE program.
incarceration of terminally ill Along with the                    In 1998 the National Institute on Corrections
aging of the general population has been a concur-            (NIC) conducted a survey on formal hospice pro-
rent aging of the prison population, which, coupled           grams. According to the study, all 12 programs were
with a fourfold increase in the U.S. prison popula-           governed by specific policies concerning admission
tion since 1980, is having a profound effect on the           procedures, special privileges for terminally ill
prison system, as the nation’s correctional institu-          inmates (relaxed visitation, who is considered “fam-
tions struggle to provide appropriate care for dying          ily,” special diets), housing options, and DO-NOT-
offenders.                                                    RESUSCITATE ORDERS. In addition, operational issues
   The number of elderly in America’s prisons is              come into play, such as: the use of inmate volun-
now 7.5 times as large as it was only one generation          teers; the appropriateness of an interdisciplinary
ago. With longer sentences and limited use of med-            approach that would allow team members to
ical parole and compassionate release, the number             include administrative or security staff, chaplains,
of terminally ill inmates is expected to grow as the          mental health staff, medical personnel, social work-
85,000 federal and state inmates age 50 and over              ers, dietitians, recreation staff, pharmacists, and vol-
“age in place,” according to Ratcliffe.                       unteers; the evaluation of the impact of links with
   May adds, “Traditionally, there has been great             outside hospice programs; and the provision of hos-
discomfort and reluctance in allowing death to                pice services to the families of the inmates.


                                                        147
148 infant death

   According to the NIC study, institutions cited the       allow the U.S. Department of Justice to begin col-
following advantages and disadvantages of their             lecting data from prisons, police lockups, and police
hospice programs:                                           departments.

Advantages:                                                 Florida House of Representatives, Criminal Justice and Cor-
                                                               rections Council. “An Examination of Elder Inmate Ser-
• Compassionate program in a difficult setting
                                                               vices: An Aging Crisis: National Institute of Corrections.
• Death with dignity                                           Videoconference. Available online. URL: http://www.
• Improved continuity of care                                  nicic.org/Resources/supplemental/PubDetails.aspx?
• Inmate volunteers say this is an enriching expe-             recordID=219. Posted 1999.
  rience                                                    GRACE Project. “Incarceration of the Terminally Ill: Current
                                                               Practices in the United States.” Volunteers of America.
• Improved inmate morale concerning health care
                                                               Available online. URL: http://www.graceprojects.org/
• Improved relationships with family members for               graceprojects/Incarceration%20of%20Terminally
  both staff and offenders                                     %20Ill%20-final%2 0_3-12-01_.pdf. Posted 2001.
• Cuts down on trips to outside hospital                    National Institute of Corrections. “Hospice and Palliative
• The program has been cost-effective because it               Care in Prisons.” Available online. URL: http://nicic.org/
  has been implemented without increase in staff or            pubs/1998/014785.pdf. Posted September 1998.
  funding                                                   May, J. P. “Improving the Quality of End-of-Life Health
                                                               Care within a Managed Care Model.” Presentation
• Decreased custodial problems
                                                               at First National Conference on Death and Dying
• Good public relations                                        in Prisons and Jails, New York, N.Y., November 16,
• Team management concept has improved overall                 1998.
  cooperation and communication                             McMahon, Patrick. “Aging Inmates Present Prison Cri-
                                                               sis.” USA Today, August 11, 2003.
Disadvantages:                                              Ratcliff, Margaret. “Dying inside the Walls.” Innovations in
                                                               End-of-Life Care 2, no. 3 (May–June 2000).
• Inmates not wanting to accept terminal diagnosis,
  distrustful of staff
• Staffing requirements and expensive full-time             infant death Infant deaths are defined as deaths of
  employees (FTEs)                                          children under one year of age. The infant death
• Need better links to community hospice program            rate (deaths among infants per 1,000 live births)
                                                            continues to be one of the most widely used indica-
• Misperceptions by security staff of the mission
                                                            tors of the overall health status of a community. The
  and value of hospice in a prison setting
                                                            leading causes of death during the first 28 days of
• Staff turnover                                            life are birth defects, premature delivery, low birth
• Security issues sometimes override hospice man-           weight, and pregnancy complications. Deaths after
  agement issues                                            the first 28 days are related to events experienced in
                                                            infancy, including SUDDEN INFANT DEATH SYNDROME
The GRACE Report notes that although “natural               (SIDS), birth defects, injuries, and homicide.
causes” continues to be the largest category of                 During the 20th century, U.S. infant mortality
inmate deaths, data that further describe those nat-        rates (IMRs) declined by 90 percent; however,
ural causes are not currently collected nationally,         many of the largest U.S. cities continue to have high
and are “difficult to obtain at the state level.” When       IMRs compared with national rates. From 1995 to
NIC conducted its 1998 survey, it found that most           1998, cities with the highest infant mortality rate
departments of correction do not keep complete              across all races and ethnicities were Memphis (15.4
data on the placement of terminally ill inmates. But        per 1,000 live births), Detroit (14.4), Washington,
that is due to change. When Congress passed the             D.C. (14.2), Norfolk (14.0), and Birmingham (13.8).
Deaths in Custody Care Act of 2000, it allocated funds to   Studies of U.S. infant mortality by region document
                                                                                            infant death 149

persisting geographic disparities and differences        of 4.5 as the target national objective rate to be
across racial/ethnic groups.                             met by the year 2010.
    Racial disparity in IMRs has not been explained         The report stresses that prevention strategies
fully by differences in socioeconomic status. Black      must focus on reducing low birth weight and very
infants born to college-educated parents have higher     low birth weight births to eliminate racial disparities
IMRs than white infants born to parents of similar       in infant mortality. “During the last decade, these
educational background; this difference is attributed    disparities have decreased, not because of reduc-
to a higher rate of very low birth weight. Education     tions in low birth weight births among blacks but
of the mother does not confer the same level of pro-     because of increases in low birth weight births
tection against infant mortality among black women       among whites. Research should be aimed at pre-
as it does among white women, suggesting that a          venting preterm delivery and associated factors
complex interaction of social, environmental, and        (e.g., infection, medical complications of pregnancy,
biologic factors that are experienced uniquely by        or poor prenatal care), and the promotion of effec-
black women might account for the disparity. Racial      tive and culturally sensitive intervention programs.
segregation is an important macrolevel predictor of      Strategies to reduce black-white disparities also
greater black-white infant mortality differences in 38   should address disparate reductions in specific med-
U.S. metropolitan statistical areas, independent of      ical conditions that lead to infant death.”
differences in median income.                               Department of Health and Human Services, 2000
    Despite higher poverty and lower education           Infant Mortality Facts:
rates, Hispanic infants have higher birth weights
and their IMRs approximate those of white infants.       • African-American infant mortality rates are more
This finding is consistent with previous studies and        than twice that of white.
contradicts common assumptions about poor,               • American Indian/Alaska Native infant mortality
underserved minority groups. Cultural practices,           rates are 45 percent higher than that of whites.
family support, selective migration, diet, and genetic
                                                         • Native Hawaiian and other Pacific Islander infant
heritage are possible contributing factors. Further-       mortality rates are 31 percent greater than that of
more, U.S. Hispanics are a heterogeneous group,            whites.
and IMRs are higher among Puerto Rican infants. In
Philadelphia, 79 percent of Hispanic births were by      • Asians have a lower infant mortality rate than
Puerto Rican mothers, possibly explaining the              whites.
higher IMR in that city (12.0 death rate).               • Substantial ethnic/racial group disparities exist.
    The findings of a Centers for Disease Control        • Some American Indian communities have infant
and Prevention report released in 2002 indicate            mortality rates that approach twice the national
that although infant mortality decreased among all         average.
races during the two decades between 1998 and            • There are subgroups in the Hispanic community
2000, the overall black-white gap for infant mor-          that have infant mortality rates higher than their
tality widened. The lack of progress in closing this       overall group rate would indicate.
gap is a consequence both of the persistence of a
                                                         • The greatest racial and ethnic disparities are seen
two- to threefold risk for low birth rate and very
                                                           in the following causes of death in infants: disor-
low birth rate among black infants compared with
                                                           ders relating to preterm birth and unspecified low
white infants, and of smaller reductions in birth
                                                           birth weight; respiratory distress syndrome; infec-
weight-specific mortality rates over time among
                                                           tions specific to the prenatal period; maternal
black, very-low-birth-rate births compared with
                                                           complications of pregnancy; and sudden infant
white, very-low-birth-rate births. If these trends
                                                           death syndrome.
persist, the report concludes, the national health
objectives to eliminate racial disparities in lower      • The rate of SIDS among African Americans, 1.6
birth weight births will not be met. In the report         deaths per 1,000 live births, is twice that of whites.
Healthy People 2010 Objective, the Department of         • Asians have the highest proportion of infant
Health and Human Services set an infant death rate         deaths from birth defects.
150 informed consent

informed consent      Consent given for a course of            attached to the inheritance, it is better to wait until
treatment, surgical procedure, or diagnostic test              they are no longer an influence before making
after being informed fully about its possible benefits          investment or purchasing decisions.
and risks. Consent is a legal requirement, and a                   In August 1997 Money magazine reported that 58
patient (or legal proxy) must be given enough infor-           percent of Americans ages 30–59 can expect to
mation about the procedure, alternatives, and the              receive an inheritance worth an average of $125,000.
competence of the medical team so that he or she               According to Worth magazine, which carried several
can make an informed decision. In addition, the                articles dealing with the good and bad of inherited
patient must also have full CAPACITY for under-                wealth in its March 2003 issue, during the next 50
standing the benefits and risks, with his or her judg-          years, families will give their heirs an astounding $25
ment not impaired at the time of consenting.                   trillion—the largest transfer of wealth in history.
   Prior to the 1970s, the doctor-patient relation-                If inheriting money and property can be bitter-
ship was based on what the doctor considered to be             sweet, allocating that inheritance can lead to even
best for the patient; there was no legal or ethical            more confusion and bitterness. According to psy-
requirement for the patient to be provided with the            chologists, parents often do not realize that their
details in order to give approval. But society’s               children (even adult children) will equate the equal-
increasing awareness of human rights has shifted               ity of the inheritance with the equality of their par-
the earlier doctor “paternalism” toward patient                ents’ love. Parents may have good reasons for
rights and the patient’s autonomy.                             leaving unequal amounts—for example, a daughter
   Crawley et al. note that “the emphasis on patient           who has helped support an aging parent for years
autonomy and informed consent that is common in                might get more, or a child who has stayed away
U.S. health care and bioethics is alien to many.               from the family for decades, may receive less. But if
Among some cultural traditions, disclosure of a seri-          parents do not discuss these decisions with their chil-
ous diagnosis and decisions about treatment are                dren, the scenario is ripe for resentment. Even dis-
sometimes made through discussions with family                 cussing it ahead may lead to problems. Goodnow
members, not the patient. The cultural belief is that          writes, “Elderly parents can be traumatized by their
families should spare patients the suffering that              children’s pre-inheritance squabbles, just as young
accompanies the responsibility of decision making.”            children are harmed by parental bickering.” Some
                                                               lawyers suggest that parents explain their distribu-
Crawley, LaVera M., et al. “Strategies for Culturally Effec-   tion of money, property, mementoes, and heirlooms
   tive End-of-Life Care.” Annals of Internal Medicine 136,    via a videotape that can be played in the lawyer’s
   no. 9 (May 7, 2002): 673–679.                               office when the will is read.
Watstein, Sarah Barbara, and Stephen Stratton. “informed           Some lawyers sense that bickering is on the rise as
   consent,” in The Encyclopedia of HIV and AIDS, Second       spendthrift baby boomers come to depend on legacies
   Edition. New York: Facts On File, 2003.                     from “the saving generation” to bail them out of debt.
                                                                   Special family circumstances are cause for special
                                                               considerations when making inheritance decisions—
inheritance Inheriting money or property can be                such as when second or succeeding marriages are
bittersweet. On the one hand, the assets received              involved, or where adoptions have occurred.
may be greatly needed, and knowing someone                         Experts say special care needs to be taken when
cared enough to leave you even a portion of their              second marriages are involved. “Never assume the
personal estate is heartwarming; on the other hand,            second spouse will take care of the children of the first
if the inheritance came from a close friend or rela-           marriage,” according to an attorney quoted by Good-
tive, spending it may reopen the feelings of loss and          now. Widows who are willing to continue raising
lead to a negative emotional response. Unless the              stepchildren need to be specifically provided for and
grieving stages have been completed, the inheri-               it should not be assumed that they will be covered.
tance may exacerbate those feelings of guilt or                    As for situations involving adopted children,
anger. Experts caution that if such feelings are               Adamec and Pierce say, “Although it would seem
                                                                       interaction with health care team 151

logical that a child adopted by nonrelatives would         became used for regular disposal of dead bodies dur-
inherit from the adoptive parents and not from             ing the Mesolithic period (10,000 to 6,000 years
birthparents (and indeed this is true in most cases),      ago), when small tools came into use. Then during
there are many ramifications of the laws regarding          the late Bronze Age, inhumation by the ancient
inheritances, and statutes vary from state to state. It    Greeks and Romans changed to CREMATION—except
is best to review current state law and consult an         for wealthy Roman infants, who were usually
attorney in the event of a question or a desire to         buried. In time, inhumation grew in popularity
provide an inheritance for an adopted-away child.”         until it completely replaced cremation.
(Two legalistic terms used when discussing inheri-
tance are adopted-away and adopted-in. An adopted-
away child is a child who is born to a family and          initiatives to improve care at the end of life
then leaves the birthparents because of adoption.          Before 1997, end-of-life research received little
An adopted-in child is a child that enters a family by     attention. Since 1997 there has been an explosion
adoption.)                                                 of initiatives to improve care at the end of life. As
   Estate taxes on inheritance may be kept to a min-       the science of end-of-life develops and currently
imum by establishing a trust or giving gifts during        funded studies are completed, it will be possible to
one’s lifetime. Attorneys and accountants need to be       further inform health care professionals and the
involved in this pre-planning.                             public about the best practices for preventing suf-
   See also LEGACY.                                        fering and improving quality of life at the end of life.
                                                           People with life-limiting conditions can benefit as
Adamec, Christine, and William L. Pierce. “inheritance     the science develops and our understanding of the
  and adoption,” in The Encyclopedia of Adoption, Second   unique aspects of care at the end of life improves.
  Edition. New York: Facts On File, 2000.
Goodnow, Cecelia. “Greed, Misunderstanding and Lack of     Knebel, Anne R. “Research Initiatives to Improve End-of-
  Communication Can Combine to Create a Clash of             Life Care.” Geriatric Times Available online. URL: http://
  Wills.” The Seattle Post-Intelligencer, July 14, 2003.     www.geriatrictimes.com/g021221.html. Posted Decem-
                                                             ber 2002.

inhibited grief     A type of abnormal grief wherein
the bereaved appears to not be affected by his or her      inquest   From the Latin “to seek into,” an inquiry
loss because the typical feelings associated with grief    to determine the cause of an unexpected death,
are not expressed. Psychiatric symptoms, especially        where there is any doubt as to its cause. The coro-
depression, may occur, but the link with the recent        ner holds the inquest, and he or she may call upon
bereavement may not be recognized either by the            a medical examiner and or a jury for assistance.
patient or the doctor.
   Some controversy exists as to whether inhibited
grief is a valid category of grief. Some experts feel      insurance     See ACCIDENTAL DEATH AND DISMEMBER-
that including such a category assumes that every          MENT INSURANCE; HOSPITALIZATION INSURANCE; LIFE
bereaved person must experience grief, and they            INSURANCE.
assert that it is possible for some individuals not to
grieve for certain losses, such as those who feel
abandoned or who were abused by the deceased, or           interaction with health care team During end-of-
where intense religious beliefs may deflect any pre-        life care, it is very important that patients and their
sumed “requirement” for a grief reaction.                  families understand the choices and ramifications of
                                                           those choices, as well as have input in decisions
                                                           being made. “Timely and compassionately provided
inhumation The ritual placing of a corpse in a             information empowers patients and families to
grave. Also called interment. Inhumation first             make informed end-of-life decisions and avoids
152 interment

painful, forced decisions during such critical times,”          Tuttas, Carol A. “The Facts of End-of-life Care.” Journal of
according to Tuttas. In order to do this, there must               Nursing Care Quality 16, no. 2 (January 2002): 10+.
be interaction with the health care team responsible
for the patient’s care.
   In a Duke University study to find out how well               interment      See INHUMATION.
physicians discuss end-of-life care with patients,
researchers found that:
                                                                inurnment      Putting ashes into an urn.
• The conversations were short (five to six minutes).
• Physicians did most of the talking.
• Only half of the time, when terms such as “life               Islam and death     Islam is practiced by about 20 per-
  support” were used, did the physician provide fur-            cent of the world’s population, concentrated in North
  ther explanation of what the term actually means.             Africa, the Middle East, South Asia, and some areas
                                                                of Southeast Asia. It is one of the fastest-growing
• Only extreme scenarios were discussed.                        religions in the United States today. According
• The values and feelings of the patients were not              to one recent survey, there are 1,209 mosques
  explored, although they did arise, per the patient,           in America, well over half founded since 1980.
  during the interaction.                                       Between 17 and 30 percent of American Muslims
• Frequently, the topic of advance directives was               are converts to the faith.
  mentioned, although 45 percent of physicians did                 For followers of Islam, called Muslims, death is
  not instruct the patient about how to actually                not final—it is just another stage of life, a transition
  obtain a written document.                                    between life on this Earth and the beginning of a life
• All of the patients expressed that they were glad             hereafter. Muslims consider death more of a separa-
  to have discussed the topic with the physician.               tion from the physical body, which will be brought
                                                                back to life on the Day of Judgment and, if God
Culture plays an important role during interaction              wills, be reunited with his or her family once again.
between patient and health care team. Thomas                       Muslims believe that everyone has a soul. They
describes a case where a home health nurse initi-               believe that after a person dies, his or her soul goes
ated conversation with an African-American                      to a world between life and death and waits there
woman with terminal cancer about nursing home                   for the Day of Judgment, at which time all the souls
placement, but out of the presence of the woman’s               who did good things in life—the just—will go to a
daughter, son-in-law, and grandchildren. The nurs-              paradise of gardens where rivers flow with milk and
ing agency was perplexed when the very angry                    honey, and the souls who did bad things in life—the
daughter called the agency and demanded a differ-               unjust—will go to hell.
ent nurse. “They did not understand either the                     Followers of Islam believe that no toxins should
reluctance of African Americans and other eth-                  be introduced into a body after death, including
nic/racial minorities to place family in nursing                chemicals for EMBALMing, which is discouraged. The
homes, or the importance of such decisions being                body is to be washed, wrapped in cloth, and after
made from a family/collective perspective.”                     prayers, buried on the same day as the death. Islam
   See also CULTURE AND DEATH.                                  accepts autopsy but only when its usefulness is
                                                                demonstrated or it is legally mandated.
Thomas, Norma D. “The Importance of Culture Through-               Muslims are against EUTHANASIA. They believe
   out All of Life and Beyond.” Holistic Nursing Practice 15,   that all human life is sacred because it is given by
   no. 2 (January 2000): 40–46.                                 Allah, and that Allah chooses how long each person
Tulsky, J. A., et al. “Opening the Black Box: How Do Physi-     will live. Human beings should not interfere in this.
   cians Communicate about Advance Directives?” Annals          Similarly, suicide is not considered a “justified” rea-
   of Internal Medicine 129, no. 6 (September 15, 1998):        son for killing. “Do not take life, which Allah made
   441–449.                                                     sacred, other than in the course of justice” (Qur’an
                                                                                        Islam and death 153

17.33). The Qur’an, pronounced and often spelled         the spirit. The family of the dead has a responsibil-
in English “Koran,” is a book of sacred writings of      ity to fulfill any debts he had as soon as possible,
Islam revealed by God to the prophet Mohammed            although anyone may pay a dead person’s debts.
during his life at Mecca and Medina, and dictates        Muslims believe that the payment of outstanding
how Muslims will live their lives.                       debts can benefit the dead by relieving them from
    As death approaches, the close family and friends    some of the punishment due to them for their neg-
try to support and comfort the dying person by whis-     ligence in repaying. Men typically carry the casket,
pering the call to prayer into the dying person’s ear.   a plain pine box, to the grave site while reciting
The idea is that the last word a Muslim should hear      verses from the Qur’an.
is Allah, reinforcing his commitment to God.                 Family and friends at the burial each put a
                                                         shovel-full of dirt in the grave and say a prayer.
           Funeral Rituals and Mourning                  After burial is completed, mourners say a final
Cremation is not permitted. In preparation for the       prayer at the grave. Sometimes, they return to the
required burial, the eyelids are closed, the body is     mosque for another gathering.
ritually washed with scented water by members of             The Muslim grave is marked by raising its top
the family, then dressed in a seamless white shroud,     level of dirt above surrounding grounds. A stone
and then taken to the mosque, where the commu-           may be used to mark its location, but no writings
nity gathers to perform a special prayer. For Mus-       are allowed. Buildings or other forms of structures
lims, paying respects to the dead is an obligation       are not allowed on top of the grave.
for everyone in a community, regardless of whether           Traditionally, three days later, more family and
each person knew the deceased.                           friends visit the home of the dead to recite verses
   In Islam, burial must occur as quickly as possible    from the Qur’an, eat together, and then pray.
following death, within 24 hours if at all possible.     Mourners are supposed to maintain contacts and
Interment must be done in an Islamic cemetery.           courteous relationships with close relatives and
Among traditional Muslims, only men may attend           close friends. Charity, fasting, prayers, and pilgrim-
burials. Unless local laws require caskets, wrapped      age are often performed on behalf of the dead. Vis-
bodies are put directly into the ground for burial.      iting the graves is recommended for the living to
The body is laid on its right side and always posi-      remember death and the Day of Judgment.
tioned to face Mecca, the direction of all Muslim
prayers. The right hand is also placed under the         Clarke, Elizabeth. “How Different Religions Handle Death
head and the head turned toward the east.                    of Faith and Forever.” Palm Beach Post, January 4,
   Funeral services are short and include a question         2002.
about whether the deceased owed any debts or if          Islamic Paths. “Death in Islam.” Available online. URL:
anyone held any grudges against the person. If so,           http://www.islamic-paths.org/Home/English/
these must be forgiven before burial in order to free        Issues/Death/TOC.htm. Downloaded July 16, 2004.
                                                                                                                  J
jazz funerals     A tradition of New Orleans, where              two-note preparatory riff to alert his fellow musi-
jazz is the fabric of life and a funeral is a major cel-         cians. At this point, the drummers begin to play
ebration of a life. The roots of the jazz funeral date           what has become known as the ‘second line’ beat.”
back several centuries to West Africa, where secret              The band now begins its return home, followed by
societies assured fellow tribesmen that a proper bur-            members of the lodge, family, friends, and then
ial would be performed at the time of death. To                  other celebrants, who have become “affectionately
accomplish this guarantee, resources were pooled to              known as the second line.” The music becomes more
form what many have labeled an early form of                     lively, even joyous, and the parade of mourners
insurance.                                                       wave elaborately decorated umbrellas “that seem to
   When slaves from these areas were brought to                  be more about styling and profiling than protection
America, the idea of providing a proper burial to fel-           from nature’s elements.” As the band marches along,
low brothers and sisters remained strong. As time                people who are able fall in “behind the band, next to
passed, these very same concepts that were rooted                the band, between the band members, affecting the
in African ideology became one of the basic princi-              body language of a dance, a strut, a ‘booty bounce’
ples of the social and pleasure club. The social and             to the music of the second-line beat.”
pleasure club guaranteed proper burial conditions as                Traditional jazz funerals began to change in the
did many fraternal orders and lodges to any mem-                 1970s, according to Marsalis. Although the jazz
ber who passed. These organizations were precur-                 funeral remains an important part of New Orleans
sors to the concept of burial insurance and debit                black culture, the younger brass band members are
insurance companies.                                             straying away from the traditional music; the stately
   The practice of having music during funeral pro-              march to the grave site is not as often a part of the
cessions was added to the basic African pattern of               event, with livelier music beginning at the church
celebration for most aspects of life including death.            door; and the newer bands are no longer attached to
As brass bands became increasingly popular during                social and pleasure clubs. “Moreover,” he writes,
the early 19th century, they were frequently called              “jazz funerals were traditionally for musicians and
on to play processional music. Eileen Southern in                club members; today they are for anyone who can
The Music of Black America wrote, “On the way to                 pay for them.”
the cemetery it was customary to play very slowly
and mournfully a dirge, or an ‘old Negro spiritual’              Marsalis, Ellis L. Jr. “New Orleans Jazz Funerals.” Ameri-
such as ‘Nearer My God to Thee,’ but on the return                  can Visions 13, no. 5. (October–November 1998): 19+.
from the cemetery, the band would strike up a rous-              Touchet, Leo, and Vernel Bagneris. Rejoice When You Die:
ing, ‘When the Saints Go Marching In,’ or a ragtime                 The New Orleans Jazz Funerals. Baton Rouge: Louisiana
song such as ‘Didn’t He Ramble.’”                                   State University Press, 1998.
   This tradition has continued through the years.
During the mournful walk toward the cemetery, the
mood is somber and there is little or no improvisa-              Judaism and death Judaism is the oldest of the
tion. After the burial ceremony has been completed,              world’s four great monotheistic religions (believing
Marsalis explains that the lead trumpeter “sounds a              in one god) and is also the smallest, with around 12

                                                           155
156 Judaism and death

million followers around the world. About 2.8 mil-        allowed, but notes that until the 18th century, most
lion, or 51 percent, of Jewish Americans follow           Jewish deaths occurred in the home and not in the
Judaism. In Europe, about 2.5 million Jews live           nursing home or hospital. “Back then there was
mostly in France, England, Russia, and the Ukraine.       ample time to view the deceased and say goodbye
Jews are divided according to their beliefs and prac-     before the ritual washing began.” She says that part
tices. Orthodox Jews follow the original teachings        of the secularization of Jewish funerals is the concept
and traditions of the faith closely. Reform Jews (a       of viewing “and reflects the culture in which we
movement begun in Germany in the early 1800s)             live”—such as family having to fly in from Los Ange-
have adapted their faith and customs to modern            les or Miami. “With the popularization of viewing,
life, and incorporated the discoveries that modern        many American Jews have accepted embalming”
scholarship has made about the early Jews. Con-           even though it is forbidden by Jewish law.
servative Jews fall somewhere between Orthodox
and Reform Jews. Death and mourning customs                          Funeral Rituals and Mourning
and rituals vary among these groups.                      The body must be buried as soon as possible, ideally
    Jews do believe in an afterlife, although the         within 24 hours. Jewish funeral customs revolve
specifics have changed through history. Orthodox           around respect for the body, beginning with never
Judaism teaches that the body will eventually be          leaving it alone. Until burial, it is watched over by
resurrected by God. Today’s more liberal Jews do          a guard called a shomer, who recites Jewish psalms.
not believe in resurrection, although many still          In preparation for burial, the body is washed in a rit-
believe in an afterlife for the soul. The Jewish          ualistic manner, then dressed in a white or muslin
heaven has two gates, with angels keeping watch           shroud without knots or bows. Friedman explains,
over them. When the righteous person approaches           “The idea is that nothing should inhibit the body’s
the gate, angels remove his burial garments and           return to the earth and that everyone, regardless of
clothe him in appropriate robes and crowns for            his or her station in life, should be equal in death.”
entry into heaven.                                           Burial takes place in a simple wooden coffin,
    Jewish law forbids any kind of EUTHANASIA or          using wooden pegs for nails. In some places, and
HASTENING DEATH, whether initiated or carried out         where allowed, the body is buried without a coffin.
by medical staff, the dying patient, or the patient’s     To begin the funeral, mourners recite the kaddish, a
family. Even though nothing can be done to shorten        memorial prayer not about death, but rather an
life, Jewish law does not require doctors to make         affirmation of life and faith in God.
the dying process last longer than it would natu-            One ritual, called Keriah, involves the tearing of
rally. Thus, if a Jewish patient is being kept alive by   a black ribbon or garment of each mourner as a
a ventilator, and would die naturally without it, it is   symbol of mourning and grief. Orthodox Jews con-
permissible to switch off the ventilator. Orthodox        tinue to tear their clothing on the left hand side
Judaism does not accept the concept of BRAIN DEATH        (over the heart) following death of a parent, and on
and defines death as the absence of respiration, car-      the right side when mourning other relatives. But
diac, and brain function.                                 Reformed or Conservative Jews are more likely to
    Jewish law does not allow cremation because this      tear a black ribbon that is pinned to their clothes.
would not allow the body to be returned to God in            During the actual burial, family and friends help
the best possible condition. Also not allowed are         fill in the grave, traditionally using the back of a
autopsies, organ donation, or embalming. If an            shovel, with the reason given ranging from a show
autopsy is required by law, a rabbi must be con-          of respect and honor to the dead, to an indication of
sulted. The process of embalming is a desecration of      a reluctance to perform this ritual.
the body, and thus not allowed—and usually not               Immediately upon returning from the cemetery,
needed because traditional Jews do not hold the           the shiva candle is lit to mark the beginning of the
WAKE or viewing so common with Christian funer-           seven days of mourning. The seven immediate fam-
als. Friedman explains that along with embalming,         ily members (mourners) who sit shiva are the
applying cosmetics to the deceased is also not            mother and father, son and daughter, brother and
                                                                                     Judaism and death 157

sister, and husband or wife. Other family members       myth and folklore.” For example, she explains that
and friends come by to comfort the mourners, and        the covering of mirrors, overturning chairs and
they bring food with them.                              breaking pots was supposedly to discourage the soul
    Traditionally, all mirrors in the home are cov-     from returning home. And the “opening and closing
ered during shiva, and these seven mourners do          of a window immediately following a death is said
not show any signs of vanity; they do not wear          to allow the departing soul to exit.”
leather shoes, put on makeup or shave, bathe                Customs vary as to when one may visit the grave
unnecessarily, wear new clothes, cut their hair, have   site. In Israel, people go on the day they finish sitting
sexual relations, conduct business, or participate in   shiva. Others wait a month, and some do not go for
entertainment. They sit on low seats to symbolize       11 months. Similarly, the tombstone unveiling may
submission to God’s will and their being brought        occur 30 days after burial or 11 months later.
low in grief, and recite the kaddish daily.
    For 30 days following their loss, mourners do       Clarke, Elizabeth. “How Different Religions Handle Death
not attend weddings or other events that have              of Faith and Forever.” Palm Beach Post, January 4, 2002.
music. The son or daughter of the deceased do not       Friedman, Stacia. “The Afterlife: An Exploration of Jew-
attend such events for a full year.                        ish Death and Bereavement Rituals Is Helping Baby
    Friedman writes, “Many Jewish customs relating         Boomers Face Their Own Mortality.” Inside 17, no. 3
to death can be traced to law, but others reside in        (September 30, 1996): 81+.
                                                                                                          K
Kevorkian, Dr. Jack (1928–      )   Michigan pathol-           murder. They did, and on April 13, 1999, he was
ogist and ASSISTED SUICIDE pioneer, who made it his            found guilty and sentenced to 10–25 years in prison.
mission to convince the medical community and                  He is serving his sentence at Thumb Correctional
lawmakers that people have a right to avoid a lin-             Facility, Lapeer, Michigan.
gering, painful death by ending their own lives with
help from physicians who can ensure that they die
peacefully. In 1990 he was present at the death of             Kübler-Ross, Dr. Elisabeth (1926–2004)        Ameri-
Janet Adkins, a 54-year-old Portland, Oregon,                  can psychiatrist who was born in Switzerland, stud-
woman with Alzheimer’s disease. Her death using                ied medicine at the University of Zürich, and became
Kevorkian’s “suicide machine” occurred in his 1968             a pioneer in the field of THANATOLOGY. Her influen-
Volkswagen van in Groveland Oaks Park near Holly,              tial On Death and Dying (1969) mapped out a five-
Michigan. For the next eight years, he admitted to             stage framework to explain the experience of dying
assisting in 100 deaths, while managing to avoid               patients, which progressed through DENIAL, ANGER,
legal penalties; he was prosecuted several times, but          BARGAINING with God, DEPRESSION, and ACCEPTANCE.
either acquitted or set free due to a mistrial. But in         A prolific writer, Kübler-Ross’s work has had lasting
late 1998 he crossed from passive to active EUTHANA-           significance among the medical community, who
SIA when he gave a man a lethal injection, rather              have generally become more responsive to the needs
than simply providing the man the means to kill                of dying patients and their families. She is also one
himself, and videotaped the act for broadcast on               of a handful of people credited with pioneering the
national TV, daring prosecutors to charge him with             American HOSPICE movement.




                                                         159
                                                                                                            L
Last Acts    A national coalition of more than 1,000              well below the 60 days considered necessary for
organizations whose main thrust is an education                   people to get maximum benefit. In fact, dying
campaign to improve care for people who are dying                 patients commonly have the support of hospice
and their families. Last Acts serves as a clearing-               care for less than a week.
house for sharing information and ideas at the                  • Hospital end-of-life care services Though the
national, state, and local levels, while providing a              number of organized palliative care programs in
forum for discussion, collaboration, and broad dis-               hospitals is increasing, such programs are not yet
semination of new information. The honorary chair                 the norm. Nor do a sufficient number of hospitals
of Last Acts is former first lady Rosalynn Carter. Last           offer pain management programs and hospice
Acts is funded by the Robert Wood Johnson Foun-                   services.
dation and Partnership for Caring.
                                                                • Care in intensive care units (ICU) at the end of
    On November 18, 2002, Last Acts released the
                                                                  life Nationwide, 28 percent of Medicare patients
first-ever “report card” on end-of-life care for the
                                                                  who die are treated in ICUs in their last six
United States. The state-by-state analysis, Means to a
                                                                  months of life. The rate varies widely, even within
Better End: A Report on Dying in America Today, graded
                                                                  individual states. Patients in ICUs typically are
all 50 states and the District of Columbia on eight
                                                                  subjected to heavy use of technology. This may be
key elements of end-of-life care. Most states earned
                                                                  at the expense of attention to comfort or against
Cs, Ds and even Fs on the majority of the criteria.
                                                                  expressed treatment preferences—often expressed
Among the report’s findings:
                                                                  as “I don’t want to die hooked up to machines.”
• State advance directive policies Some states’ laws            • Persistent pain among nursing home residents
  include confusing language or create bureaucratic               Nearly half of the 1.6 million Americans living in
  hurdles that make it difficult for citizens to express           nursing homes have persistent pain that is not
  their preferences or to designate appropriate sur-              noticed and not adequately treated.
  rogate decision-makers.                                       • State pain management policies All states have
• Location of death Although research shows that                  laws addressing the use of controlled substances.
  70 percent of Americans would prefer to be at                   Some are effective, but others create formidable
  home with loved ones in their final days, only                   barriers to good pain management.
  about 25 percent die at home. Where people                    • Number of physicians and nurses certified in pal-
  die—in a hospital, a nursing home, hospice, or at               liative care Palliative care training for the
  home—depends on the state or community                          nation’s physicians and nurses lags far behind the
  where they live and the health care resources                   needs of the aging U.S. population. This is true for
  available there. Research has shown that these                  medical and nursing students, as well as for the
  factors outweigh patient preferences.                           hundreds of thousands of professionals already in
• Rate of hospice use Hospice care is a “gold stan-               practice.
  dard” for end-of-life care. However, hospice is
  not widely used in most states. Furthermore, the              Last Acts does have its detractors. A coalition of
  average length of stay in hospice has dropped to              people with chronic disabilities has voiced displeas-

                                                          161
162 last hours of living

ure at Last Act’s spinoff organization, called Last          dying is known as Viaticum, or the reception of the
Chapters, which is included in its Web site and fea-         Eucharist for the last time.
tures articles and essays detailing the complexities of
“living with dying.” Included among these articles
are stories of people living with Parkinson’s, Crohn’s       laws    The federal funeral law, called the FUNERAL
disease, and rheumatoid arthritis—diseases that              RULE, is enforced by the Federal Trade Commission
may be lifelong, but are not terminal in themselves.         and primarily addresses disclosure of prices and
People with such diseases are concerned that label-          other consumer concerns by funeral directors. Most
ing such persons as “dying” sends a message counter          states and local jurisdictions have laws regarding
to the long-standing work of the disability commu-           funerals and burial. To find out what those require-
nity to communicate the potential of living, work-           ments are, one should contact the appropriate
ing, and contributing even with such disabilties.            licensing agency, which is often the Department of
                                                             Health, or the state attorney general.
                                                                 In 2003 the General Accounting Office (GAO)
last hours of living   With fewer than 10 percent of         conducted a study of state funeral laws. The GAO
us dying suddenly, the vast majority can expect to           report found that third-party sales of funeral goods
die after some time period of illness, with gradual          are largely unregulated, that few states require regu-
deterioration until an active dying phase at the end.        lar cemetery inspections, and that a broad disparity
In their handbook for physicians, Emanuel et al.             exists in both the way states regulate various seg-
caution that most people have little or no actual            ments of the death-care industry and the mecha-
experience with those last hours of life and thus            nisms in place to enforce such regulations. According
base their expectations on an exaggerated sense of           to the report, while funeral homes themselves are
what dying and death are like, “based on media               generally regulated and licensed, other businesses
dramatization and our vivid imaginations.” The               providing death-care services, such as crematories,
authors stress to physicians and nurses that if man-         cemeteries, and funeral-goods salesman are not.
aged well, the last hours can lead to significant per-
sonal and family growth; but if managed poorly, life
closure may be incomplete, suffering may occur               leading causes of death      Data released by the
unnecessarily, family distress may continue long             National Center for Health Statistics showed the
after the patient’s death, and those who watch may           10 leading causes of death in the United States for
worry that their own death will be similar.                  2001 as:
   See also BODILY DETERIORATION AS DEATH
APPROACHES; DYING PROCESS; DYING TRAJECTORY; EDU-            1.  Heart Disease
CATION FOR PHYSICIANS ON END-OF-LIFE CARE (EPEC).            2.  Cancer
                                                             3.  Stroke
Emanuel, L. L., C. F. Von Grunten, and F. D. Ferris. “Last
                                                             4.  Chronic Lower Respiratory Disease
  Hours of Living.” The Education for Physicians on End-
  of-life Care curriculum, Institute for Ethics, American    5.  Accidents
  Medical Association. Available online. URL: http://www.    6.  Diabetes
  ama-assn.org/ethic/epec/download/module_12.pdf.            7.  Pneumonia/Influenza
  Posted 1999.
                                                             8.  Alzheimer’s Disease
                                                             9.  Nephritis, nephrotic syndrome, and nephrosis
last rites  Rites performed in connection with a                 (kidney-related)
death or burial. Also a sacrament of the Roman               10. Septicemia (blood poisoning)
Catholic Church once called extreme unction or
“the last anointing.” With Vatican (Council) II and          (See also table of “Leading Causes of Death by Pop-
the reform of the liturgy, the sacrament for the             ulation Group” in Appendix III. It lists 2001 census
                                                                legislation related to end-of-life care 163

figures for American Indian/Alaska Native, Asian            to develop standards for evaluating end-of-life
American, Black or African American, Hispanic or           care. Establishes an Advisory Committee on End-
Latino, Native Hawaiian and Other Pacific Islander,         of-Life Care to advise the secretary of HHS and the
Multiracial, White, Men, and Women population              CMS administrator. Funds a 24-hour hotline for
groups.)                                                   information, referral, and direct assistance to
                                                           patients and families dealing with end-of-life care.
                                                           Awaiting introduction in the 108th Congress (S.
legacy Something handed down or left behind by             2489 in the 107th Congress).
the deceased for future generations. Typically, a        • Lifespan Respite Care Act (S 538 HR 1083)
legacy is thought of as concrete, material items, such     Authorizes grants to promote a coordinated sys-
as money, life insurance, or real estate, but a legacy     tem of accessible respite care services for family
may also be a philosophy or belief system, spiritu-        caregivers of individuals with special needs.
ality, or even the fun of a playground for children in     Authorizes funds for recruiting and training
an urban ghetto. ELISABETH KÜBLER-ROSS’s legacy            respite care providers and volunteers. Authorizes
has been said to be: “to have transformed the way          $125 million for Fiscal Year (FY) 2003; $150 mil-
the medical community thinks.”                             lion for FY 2004; $175 million for FY 2005; $200
    See also INHERITANCE.                                  million for FY 2006; and $225 million for FY
                                                           2007. Introduced March 5, 2003. Approved
Boyles, Denis. “Lasting Impressions.” AARP 45w, no. 5      unanimously (21–0) by the full Senate Health,
  (September/October 2002): 80–87.                         Education, Labor and Pensions (HELP) Commit-
                                                           tee on March 19, 2003. Passed by the Senate on
                                                           April 10, 2003.
legal issues in end-of-life care    Although most
                                                         • Medicare Payment Restoration and Benefits
end-of-life decisions would appear to be personal in
                                                           Improvement Act of 2003 (HR 26) Allows for
nature, with only family, doctor, and clergy
                                                           Medicare coverage of hospice consultation serv-
involved, some of the most central issues related to
                                                           ices when a patient is diagnosed with a terminal
end-of-life care and decision-making are governed
                                                           illness. Establishes a rural hospice demonstration
by state or federal laws. Some decisions might be
                                                           program. Increases by 10 percent the reimburse-
defensible under ethical principles, but they might
                                                           ment rate for hospices in frontier areas. Intro-
not be permissible under legal provision. Among
                                                           duced January 7, 2003.
the issues that may be governed by law rather than,
or along with, personal decision are: prescription       • Rural Communities Hospice Care Access Improve-
pain medication such as OPIATES/OPIOIDS; DO-NOT-           ment Act of 2003 (S. 114 HR 754) Removes the
RESUSCITATE ORDERS; ADVANCE DIRECTIVES; ASSISTED           20 percent inpatient limitation under the
SUICIDE; LIVING WILL; PATIENT SELF-DETERMINATION           Medicare program on the proportion of hospice
ACT; and INFORMED CONSENT.                                 care that certain rural hospice programs may pro-
                                                           vide. Introduced January 9, 2003.
                                                         • Health Care Coverage Expansion and Quality
legislation related to end-of-life care
                                     A few bills           Improvement Act of 2003 (S. 10) Contains
introduced during the 108th Congress (2003–04)             “continuity of care” provisions stipulating that, if
focus on end-of-life care:                                 a health insurance contract is terminated or
                                                           switched, certain patients may remain under the
• Advanced Directives and Compassionate Care Act           care of their current health care provider(s) and
  Mandates portability for advance directives, i.e.,       the new plan must reimburse those providers even
  states would have to honor advance directives            if the providers are not participating in the new
  filled out in any other state. Directs the Depart-        plan. Defines “terminally ill” patients as among
  ment of Health and Human Services (HHS) and              those who must be given the option of remaining
  Centers for Medicare & Medicaid Services (CMS)           under the care of the provider(s) currently treating
164 lie in state

  the terminal illness. These patients may continue        dented jump of almost 30 years between 1900 and
  receiving services from current providers for the        1975.” Increases in life expectancy since 1960 have
  remainder of their lives. Introduced January 7,          been due in part to better medical control of cancer,
  2003.                                                    heart disease, and stroke.
                                                               Although life expectancy in the United States
                                                           was the highest ever in 2002, infant mortality
lie in state   To be displayed formally to the public      increased from a rate of 6.8 infant deaths per 1,000
before burial; an honor reserved for heads of state,       live births in 2001 to a rate of 7.0 per 1,000 births
government leaders, and a few who die as national          in 2002, the first year since 1958 that the rate has
or state heroes. Sometimes the body is placed in a         not declined or remained unchanged.
glass-topped coffin; in any case, the position of the           The 2002 Centers for Disease Control and Pre-
casket will allow members of the public to walk past       vention report, released in February 2004, attributes
it and pay their respects. Typically, the casket will be   the rise in infant mortality to an increase in neona-
placed on a bier, and nearby may be an honor               tal infant deaths (infants less than 28 days old), par-
guard, display flowers, and draped flags.                    ticularly infants who died within the first week of
                                                           life. However, there was a continued decrease in
                                                           late-term fetal deaths, defined as 28 or more weeks
life after death   See AFTERLIFE.                          of gestation. Three causes of death accounted for
                                                           most of the increase in infant mortality: congenital
                                                           anomalies (birth defects), disorders related to short
life expectancy The average number of years                gestation and low birth weight, and maternal com-
people live. The dictionary defines life expectancy as      plications of pregnancy. Deaths from sudden infant
“an expected number of years of life based on sta-         death syndrome (SIDS) declined between 2001 and
tistical probability,” a probability that is calculated    2002, continuing a long-term downward trend.
by examining the survival rate for a specific popu-             The report cited 27,977 infant deaths nationwide
lation (for example, everyone born in 1925 or              in 2002, up from 27,568 in 2001, out of about 4 mil-
everyone born in 1990), and then using that as the         lion births each year. The report tracked more than
probability that people in that population will live to    130 causes of infant death, but more detailed infor-
a particular year. Americans’ life expectancy hit an       mation was scheduled to become available in 2004
all-time high of 77.4 years in 2002, up from 77.2 in       when linked birth and death records were to be ana-
2001 and 77 in 2000, and increased for both men            lyzed by the National Center for Health Statistics.
and women as well as whites and blacks. For men,               Overall, death rates for the total U.S. population
life expectancy increased from 74.3 years in 2000 to       dropped in 2002. The national age-adjusted death
74.4 years in 2001; for women, life expectancy             rate decreased slightly from 855 deaths per 100,000
increased from 79.7 years to 79.8 years. Record high       population in 2001 to 847 deaths per 100,000 in
life expectancies were observed in 2002 for both           2002. There were declines in mortality among most
men and women, and for African Americans and               racial, ethnic, and gender groups except for Amer-
whites.                                                    ican Indians (both males and females) and non-
    Roy and Russell explain that “over the centuries       Hispanic white females, whose death rates remained
average life expectancy has increased from about           unchanged from 2001.
age 20 in ancient Rome some 2,000 years ago                    Among the nation’s leading causes of death,
(death in childhood and youth were common there            there were declines in mortality from heart disease
owing to the lack of sanitation and medical know-          (3 percent), stroke (nearly 3 percent), accidents/
how) to about age 40 at the time that the pilgrims         unintentional injuries (nearly 2 percent), and can-
came to America. Between the time of the pilgrims          cer (1 percent). The biggest decline in mortality
and 1900, life expectancy in America grew slowly to        among the leading causes of death was for homi-
about age 47. After the turn of this century it            cides—down 17 percent. That number had increased
exploded with an increase to 75 years, an unprece-         sharply in 2001 due to the September 11 terrorist
                                                                            life-prolonging decision making 165

attacks. Excluding the September 11 deaths, the                ance accumulates a cash value, which can be bor-
decrease from 2001 to 2002 would have been 3 per-              rowed against. Any such loans must be paid back
cent, which still reflects a continuing downward               with interest or the named beneficiaries will receive
trend in homicides that began in 1991.                         a reduced death benefit.
   There has also been a continued decline in the                 Once the insured has died, the beneficiary or
preliminary age-adjusted death rate from HIV/AIDS,             executor of the estate needs to contact the insurance
which dropped 2 percent between 2001 and 2002.                 agents or companies holding coverage on the
HIV mortality has decreased approximately 70 per-              deceased. The companies’ contact information will be
cent since 1995, but remains the fifth leading cause            printed on the policies; the agents’ business cards
of death for people ages 25 to 44.                             may be attached to the policies. Each company will
   Mortality rates increased for some leading causes           want the original life insurance policies or policy
of death, including Alzheimer’s (up 5.8 percent),              numbers, plus a certified copy of the death certificate.
influenza and pneumonia (up 3.2 percent), high                     Once a company has verified that the necessary
blood pressure (up 2.9 percent), and septicemia or             premiums to keep the policy “in force” were paid to
blood poisoning (up 2.6 percent).                              the date of death (or to completion if it is, for exam-
   In February 2004, the Canadian Population                   ple, a whole life 20-year-pay policy), the life insur-
Health initiative released a report, Improving the             ance company should promptly pay the benefits,
Health of Canadians, which stated that the top 20              assuming that everything is in order and the policy
percent of income earners in Canada live, on aver-             has been in effect for at least two years. (Once the
age, about five years longer than the lowest 20 per-            policy is at least two years old, it is in the “incon-
cent. The aboriginal, consistently among the poorest           testable period” and must be paid, except in extraor-
of the poor, can expect to live, on average, 10 years          dinary circumstances.) If death occurs within the
less than a non-native, and infant mortality rates in          two-year contestable period, it may still pay off in
Indian and Inuit communities are three times the               full, but the company has the right to investigate
national average. Between 1971 and 1996, income                whether all information provided when the policy
has risen considerably and the life expectancy of              was started, especially regarding the deceased’s
Canadians in all income groups has also risen, with            health at that time, was accurate.
the life expectance of the poor about the same today              Even if premiums on the policy were not cur-
as it was for the rich 25 years ago.                           rently being paid, the policy may have enough cash
                                                               value to keep it in force for a period of time, so it is
Centers for Disease Control and Prevention. Deaths: Prelim-    always a good idea to check out any life insurance
  inary Data for 2002. Available online. URL: http://www.      policies found among the deceased’s possessions.
  cdc.gov/nchs. Posted February 2004.                             According to insurance companies, processing a
Roy, F. Hampton, and Charles Russell. “life expectancy,” in    standard policy death claim should take only one to
  The Encyclopedia of Aging and the Elderly. New York: Facts   four weeks from the time the insurer’s claims office
  On File, 1992.                                               has all the needed paperwork.


life insurance    Proceeds paid to named beneficiar-            life-prolonging decision making At some time,
ies when the insured person dies. There are two                when a person is suffering a lingering death with no
basic kinds of life insurance: term and permanent.             hope of cure, the decision will have to be made by
Term insurance covers the insured for a specified               the medical team, the patient, and family or desig-
length of time. It pays a benefit only if the insured           nated proxy whether to use whatever means are
dies during that term. Mortgage insurance is a typ-            available to prolong the patient’s life, or whether to
ical use for term insurance. Permanent insurance—              simply keep the patient as comfortable as possible
including whole, ordinary, universal, adjustable,              and let nature take its course.
and variable life—is protection that can be kept in                Such decisions are equally difficult for the med-
force for as long as you live. Permanent life insur-           ical staff and the family. In 1998, the British Medical
166 life support systems

Association’s Medical Ethics Committee published           and, where appropriate, those close to the patient.
guidelines in this area. Among its suggestions:            Where the clinician’s view is seriously challenged
                                                           and agreement cannot be reached by other means,
• Where there is reasonable doubt about its poten-         review by a court would be advisable.
  tial for benefit, treatment should be provided for
  a trial period with a subsequent prearranged           British Medical Association. “Withholding and Withdraw-
  review. If, following the review, it is decided that      ing Life-Prolonging Medical Treatment: Guidance for
  the treatment has failed or ceased to be of bene-         Decision Making.” Available online. URL: http://
  fit to the patient, consideration should be given to       www.bmjpg.co.uk/withwith/contents.htm. Updated
  its withdrawal.                                           April 24, 2001.
• Before a decision is made to withhold or withdraw
  treatment, adequate time, resources, and facilities
  should be made available to permit a thorough          life support systems Medical procedures or inter-
  and appropriate assessment of the patient’s condi-     ventions that, when applied to an individual, aid,
  tion including, where appropriate, the patient’s       support, or replace a vital function of the body that
  potential for self-awareness, awareness of others,     has been seriously damaged. Such techniques
  and the ability intentionally to interact with them.   include artificial pacemakers, internal defibrillators,
  This should involve a multidisciplinary team with      dialysis machines, respirators, and artificial means of
  expertise in undertaking this type of assessment.      providing nutrition or hydration. The use of life sup-
• The benefits, risks, and burdens of the treatment       port systems to postpone the moment of death—
  in the particular case should be assessed.             also called life-sustaining treatment—or to maintain
                                                         the individual in a state of permanent unconscious-
• Although ultimately the responsibility for treat-
                                                         ness sometimes raises such ethical issues as the
  ment decisions rests with the clinician in charge
                                                         QUALITY OF LIFE, EUTHANASIA, and the right to die,
  of the patient’s care, it is important, where non-
                                                         and has been the subject of much legal and moral
  emergency decisions are made, that account is
                                                         debate. Some people specify their wishes concerning
  taken of the views of other health professionals
                                                         prolonged artificial life support, especially should
  involved in the patient’s care and people close to
                                                         they be in a PERSISTENT VEGETATIVE STATE, in a LIVING
  the patient, in order to ensure that the decision is
                                                         WILL. A HEALTH CARE PROXY is another legal means of
  as well informed as possible.
                                                         ensuring that a person’s wishes regarding artificial
• Even where their views have no legal status,           life support are respected, even if the person is
  those close to the patient can provide important       unable to communicate those wishes.
  information to help ascertain whether the patient
  would have considered life-prolonging treatment
  to be beneficial.                                       living trusts A legal arrangement created during a
• Good communication, both within the health             person’s lifetime, which lets that person control the
  care team and between the health team and the          distribution of his or her estate. The key element of
  patient and/or those close to the patient, is an       a living trust is that it can be changed or revoked at
  essential part of the decision making. Wherever        any time during the donor’s life. The way it works
  possible, consensus should be sought among all         is that you transfer ownership of your property and
  those consulted about whether the provision of         your assets into the trust. You can serve as the
  life-prolonging treatment would benefit the            trustee or you can select a person or an institution
  patient.                                               to be the trustee. If you are the trustee, you will
• Decisions to withhold or withdraw conventional         have to name a successor trustee to distribute the
  treatment, on the basis that it is not providing a     assets at your death.
  benefit to the patient, should be made by the clini-        The advantage of a living trust is that, properly
  cian in overall charge of the patient’s care follow-   drafted and executed, it can avoid probate because
  ing discussion with the rest of the health care team   the trust owns the assets, not the deceased. Only
                                                                                                   living will 167

property in the deceased’s name must go through                not want to be kept on a ventilator if he can no
probate. After January 1, 2004, a husband and wife             longer breathe on his own can direct that such a
with a properly drafted set of trusts can pass $3 mil-         procedure not be performed. Or a person may state
lion down to their children without paying any fed-            in her living will that she not be fed through a tube
eral estate taxes. The possible disadvantage of a              if such a procedure is being done only to prolong her
living trust is that poorly drawn or unfunded trusts           life. Under certain conditions, it permits doctors to
can result in additional costs and endanger one’s              withhold or withdraw life support systems. In the
best intentions.                                               absence of a living will, medical care decisions are
    Living trusts can be revocable or irrevocable. The         generally made by a spouse, guardian, health care
most popular type of trust is the revocable living             agent, or a majority of parents and children. But if
trust, which allows the individual to make changes             family members and doctors have difficulty deciding
to the trust during his or her life. Revocable living          on medical care, the matter could be decided in
trusts avoid the often lengthy probate process but,            court. Other names for this type of document
by themselves, do not provide shelter for assets from          include “directive to physicians,” “health care decla-
federal or state estate taxes.                                 ration,” or “medical directive.” Regardless of what it
    When an irrevocable living trust is set up, own-           is called, this document’s purpose is to guide family
ership of the assets is turned over to the trustee. The        and doctors in deciding how aggressively to use
trust becomes, for tax purposes, a separate entity,            medical treatments intended to delay death.
and the assets cannot be removed, nor can changes                  Only 36 percent of Americans have a living will,
be made by the grantor. This type of trust often is            according to a 2004 survey by the legal Web site
used by individuals with large estates to reduce               FindLaw (http://www.findlaw.com). FindLaw offers
estate taxes and avoid probate. However, if the                the following suggestions for creating a living will:
grantor names himself or herself as trustee or is
entitled to trust income, the tax benefits would gen-           • Make sure your living will conforms to your state’s
erally be lost.                                                  laws. A living will must meet specific legal require-
    The Better Business Bureau cautions that many                ments. For example, some states require it contain
consumers have lost thousands of dollars by buying               specific language and be signed in the presence of
living trust kits that turned out to be virtually                two qualified witnesses as well as certified by a
worthless.                                                       notary public or a clerk of the superior court.
                                                               • Make clear, consistent choices. To be effective,
Better Business Bureau, New York. What You Need To Know          the document should specify not only whether
   about Living Trusts. Available online. URL: http://           you want extraordinary life-saving measures, but
   www.newyork.bbb.org/seniorsolutions/pdfs/bbb_srsol_           also whether you wish to receive pain medica-
   trusts.pdf. Downloaded August 28, 2003.                       tion, artificial nutrition, or hydration.
Federal Trade Commission. Living Trust Offers: How to Make
   Sure They’re Trust-worthy. Available online. URL: http://
                                                               • Store extra copies. Keep the original in a place
   www.ftc.gov/bcp/conline/pubs/services/livtrust.pdf.
                                                                 where family members can easily find it. If your
   Posted July 2000.
                                                                 state law allows, you may wish to sign several
NOLO Law Center. “Living Trust FAQ.” NOLO Law Center.
                                                                 copies, have each witnessed and certified, and
   Available online. URL: http://www.nolo.com/lawcenter/
                                                                 give an original to the appropriate people, such as
   ency/index.cfm. Downloaded August 28, 2003.                   family members and family physicians. However,
                                                                 if you change your mind and revoke or change
                                                                 your living will, make sure you destroy all origi-
living will An ADVANCE DIRECTIVE that tells what                 nals and copies.
life-sustaining medical treatment a person does or             • Appoint a health care agent. You may wish to
does not want if he or she is not able to make his or            designate a specific person as your health care
her wishes known, such as during a terminal state of             agent by signing a health care power of attorney
unconsciousness. For example, a person who does                  or general durable power of attorney document.
168 livor mortis

  The health care agent will then have the author-            when touched, indicates that lividity is not yet per-
  ity to carry out your wishes and make decisions             manent, which indicates that death likely occurred
  regarding your care.                                        between two and 10 hours ago.
• Review your living will if you move. A living will             See also ALGOR MORTIS; RIGOR MORTIS.
  may not be valid if you move to another state. If
  you spend a significant amount of time in
  another state, you may want to sign a living will           local death   Death of a part of the body or of a tis-
  for each state. However, in some states, this may           sue by necrosis, such as gangrene.
  invalidate previously signed living wills.
• Consult an estate-planning attorney. Living wills
  and powers of attorney may be invalidated or                loneliness A common feeling experienced during
  contested if there are errors or problems in con-           bereavement. In a Swedish study of the elderly
  forming to state law.                                       where one spouse had died, feeling lonely was the
                                                              most persistent problem during the first year fol-
Last Acts. Thinking Ahead: Advance Planning for End-Of-Life   lowing loss of the spouse. Loneliness is also com-
   Care. Available online. URL: http://www.lastacts.org/      monly experienced by the dying and can lead to
   files/misc/THINKINGAHEAD.pdf. Downloaded July              depression. In a 2002 study of patients dying in
   16, 2004.                                                  nursing homes, 21 percent experienced loneliness.


livor mortis    Also known as lividity or hyposta-            long-term care     A residence in which some level of
sis—the pooling of blood in the “dependent parts”             personal care is provided, with stays varying from
or lowest points of the body after circulation ceases.        several weeks to many years, including the rest of
It refers to the dark purple or maroon color that             one’s life. Among long-term care facilities are
develops after the heart stops and no longer churns           assisted living, rehabilitation centers, and nursing
the blood; heavier red blood cells settle downward            homes. Today, long-term care may also apply to
from the plasma by gravity. Livor mortis begins               home health care and homemaker services. People
immediately following death, and is visible within a          who require long-term care have chronic illnesses or
couple of hours. It settles in permanently within             disabilities that do not require the intensive super-
eight to 10 hours.                                            vision and acute care provided in hospitals. Their
    Livor mortis is one of several factors investigators      health condition, however, makes them heavily
look at when trying to determine time, location,              dependent on others for supervision or assistance
and cause of death. Although typically lividity has a         with activities of daily living. Not all people receiv-
purple or reddish-purple color, lividity in deaths            ing long-term care are elderly, but the majority are.
from exposure to the cold is bright pink. In deaths
from carbon monoxide poisoning, lividity is a cherry
red; in other types of poisoning, a chocolate brown.          long-term care insurance Long-term care is
Cyanide poisoning results in lividity described by            expensive: A nursing home stay costs $50,000 to
different authors as pink, scarlet, and violet. The           $100,000 a year, according to Tom Scully, Adminis-
lividity does not occur where the body is in contact          trator, Centers for Medicare & Medicaid Services,
with something; thus, a body lying on its back will           Department of Health and Human Services, in his
show lividity in the small of its back and its neck,          report to the Senate Finance Committee on July 17,
but not in parts of the body directly touching the            2003. The average stay in a nursing home is 2.6
ground, which helps determine if a body has been              years with the total cost averaging $137,500.
moved after death. Similarly, if a body is found lying        Although such care is subsidized by the federal
on its back, but the lividity appears on the front or         Medicare program and the federal/state Medicaid
one side, then the corpse has been moved since                program, Medicare is time-limited, and to qualify
death. Skin that shows lividity, but pales to white           for Medicaid, one must “spend down” assets. Since
                                                                            long-term care insurance 169

the mid-1970s, an alternative to financing long-term     mum of $1,000 and more likely closer to $2,000 per
care is long-term care insurance, but experts caution   year in premiums without touching money needed
that such insurance coverage is not for everyone.       for regular current living expenses. If begun when a
Long-term care policies can be purchased on an indi-    person is in his or her 40s, these premiums may
vidual basis and, increasingly, through group plans     have to be paid for as long as 40 years before the
offered by employers. Most pay a fixed dollar           need for long-term care occurs.
amount—$50 to $250 a day—for the time period
chosen by the policyholder. Premiums are lower the      Kaiser Family Foundation. “Private Long-Term Care
younger age at which one begins paying; plus,              Insurance: Who Should Buy It and What Should They
because insurers will not cover preexisting condi-         Buy?” Kaiser Family Foundation. Available online.
tions, waiting until one is older to take out such a       URL: http://www.kff.org/insurance/6072-index.cfm.
policy may be too late if a long-term disease such as      Downloaded July 16, 2004.
Alzheimer’s has already been diagnosed. Because of      Richard, Alexander, ed. “Avoiding Fraud When Buying
its cost, experts say long-term insurance makes most       Long-Term Care Insurance: A Guide For Consumers
sense for people with at least $75,000 in assets, who      And Their Families.” The Consumer Law Page. Available
do not have children or other relatives who can help       online. URL: http://consumerlawpage.com/article/
out with long-term care, and who can pay a mini-           insure.shtml. Downloaded August 30, 2003.
                                                                                                           M
managed care      Systems used to manage the use of            the funeral liturgy and join with the bereaved fam-
health care services, including a review of medical            ily in the celebration of the funeral rites by serving
necessity, incentives to use certain providers, and            at the altar and, if needed, helping with the distri-
case management. Managed care has effectively                  bution of communion. Prior to the reformation of
formed a “go-between” brokerage or third party                 the Roman Catholic liturgy following the Second Vat-
arrangement by existing as the gatekeeper between              ican Council (1962–65), it was called the Requiem
payers and providers and patients. Usually a refer-            Mass. Among other changes, black vestments are no
ence to a managed care organization is referring to            longer required; in their place, white or purple may
the entity (such as health maintenance organization            be worn, and flowers are permitted.
or HMO) that manages the risk, contracts with
providers, is paid by employers or patient groups, or
handles claims processing. Each managed care plan              maternal mortality At the beginning of the 20th
is different. Some require health care to be provided          century, for every 1,000 live births, six to nine
at specific locations or by particular doctors, and if          women in the United States died of pregnancy-
it is not, they may not pay as many benefits.                   related complications. From 1900 through 1997,
                                                               the maternal mortality rate declined almost 99 per-
                                                               cent to less than 0.1 reported death per 1,000 live
man-made death Term used for preventable deaths                births (7.7 deaths per 100,000 live births in 1997).
of large numbers, such as death from war or political             Significant disparities between black and white
violence. Some researchers call for man-made death             mothers exist in regard to maternal mortality. Black
to be monitored, nation by nation, to expose to pub-           women face a higher risk of maternal mortality,
lic view national responsibility for a major loss of           regardless of the level of prenatal care received dur-
human life and thereby encourage its reduction.                ing their pregnancy. In 1998, black mothers were
                                                               four times as likely to die from pregnancy complica-
                                                               tions as white mothers; the mortality rate due to
markers    See GRAVE MARKER; GRAVESTONE.                       pregnancy complications for black mothers was also
                                                               more than three times the rate for Hispanic mothers.
                                                                  Between 1993 and 1997, maternal mortality
Mass of Christian Burial    Also called Funeral Mass           rates for American Indian/Alaska Native, Hispanic,
or Mass for the Dead. Roman Catholics celebrate the            and Asian and Pacific Islander mothers were higher
Mass at the time of death as an expression of their            than the rates for non-Hispanic white mothers,
faith in God’s abundant mercy and in Jesus Christ,             although lower than the rates for non-Hispanic
and their hope in the resurrection of the dead. Fam-           black mothers. The rates were: among American
ily members may choose the Scripture reading for               Indians/Alaska Natives, 12 maternal deaths per
the Mass, cover the casket with the PALL, place Chris-         100,000 live births; among Asian/Pacific Islanders,
tian symbols on the casket (crucifix, Bible), and pres-         11 deaths per 100,000 births; and among Hispanics,
ent the bread and wine at the preparation rite.                10 deaths per 100,000 births. There were slightly
Members of the parish community also participate in            more than seven deaths per 100,000 live births

                                                         171
172 mausoleum

among white mothers, but almost 30 deaths per           mausoleum with other individuals makes it more
100,000 live births to black mothers. When exam-        affordable than a private mausoleum. Crypts are
ined by nativity, foreign-born Asian and Pacific        designed to hold casketed remains. Following a cas-
Islander and Hispanic mothers have pregnancy-           ket entombment, the crypt is sealed, and a granite
related mortality rates higher than their U.S.-born     or marble front is attached. Niches will accommo-
counterparts. Foreign-born Latino mothers were 50       date urns containing cremated remains. Following
percent more likely to die of pregnancy complica-       an urn entombment, a niche front of granite, mar-
tions—nearly 12 per 100,000 versus a death rate of      ble, bronze, wood, or glass is attached. With the
eight per 100,000 for U.S.-born Hispanic women.         growing shortage of available land for cemetery use,
Foreign-born Asian and Pacific Islander mothers,         mausoleums are becoming more utilized because
however, have maternal mortality rates that are         they allow for a maximum number of entombments
twice as high as the rates for U.S.-born Asian and      in a minimum amount of space. In most cases, the
Pacific Islander mothers.                                cost of community mausoleum entombment is
                                                        comparable to the costs of interment in a lot with an
                                                        upright monument.
mausoleum A large, freestanding, and above-
ground burial chamber. The name mausoleum comes         Keister, Douglas. “A Brief History of the Community
from a large temple-like structure built as a final        Mausoleum.” Cemetery Junction. Available online.
resting place for King Mausolus of Caria, in Asia         URL: http://www.daddezio.com/cemetery/articles/
Minor, by his wife Artemisia following his death in       mausoleum.html. Posted April 5, 1999.
353 B.C.E. Located in the ancient city of Halicarnas-
sus, his mausoleum is now regarded as the fifth of
the Seven Wonders of the Ancient World. The pyr-        Medicaid      Government sponsored health- and
amids of Egypt and the Taj Mahal in India are other     long-term care insurance for those who do not
examples of ancient mausoleums. Prior to that time      qualify for MEDICARE, or who cannot afford to pay
most people were buried in the ground and soon for-     costs that are only partially covered by Medicare
gotten, with a few being cremated and their remains     insurance. Medicaid is a major source of financing
left unmarked. Except for those rulers who had          for end-of-life care, covering long-term care costs in
reached godlike status, people gave little thought to   nursing homes and at home, plus HOSPICE care,
memorializing the dead. But the idea of a mau-          whereas Medicare does so only in exceptional cir-
soleum caught on with royalty, who were the only        cumstances and for a limited number of days. Indi-
ones with the land and the wealth to erect mau-         viduals who exhaust their income and property
soleums. Then Queen Victoria, while mourning her        resources while personally paying for long-term
beloved Albert, made cemeteries and memorializa-        care become eligible for Medicaid. As The Wall Street
tion fashionable, hastening the evolution of modern     Journal has reported, for years, thousands of middle-
mausoleums. Keister writes, “Most importantly (for      class and even affluent retirees—terrified that long-
the establishment of the community mausoleum)           term and end-of-life health care costs could wipe
were the folks in Spain who figured out a way to         out their savings—have transferred their assets to
make above ground burial affordable to the masses.      relatives in order to qualify for Medicaid. But with
Examples of their tidy invention, wall vaults (also     Medicaid having become the largest cost item on
known as oven vaults and side vaults), may be seen      some states’ budgets, and with states facing their
in the cemeteries of New Orleans. Society tombs         worst financial crises in decades, more and more
expand the idea of wall vaults. These tombs, com-       states are initiating legislation that would make it
posed of multiple crypts, were built by fraternal       harder for residents to shelter assets, plus are being
organizations, such as the Elks or other ‘protective    more aggressive in recouping some of the money
and benevolent associations.’”                          after an individual dies. For example, a new law in
   A community mausoleum is a large building            2003 allows Massachusetts to recoup Medicaid
designed to provide above-ground entombment for         money by selling the jointly owned homes of eld-
a large number of people. Sharing the costs of the      erly recipients after they die, which critics complain
                                                                                                  Medicare 173

could make it harder for elderly parents to pass their     comfort level. Physicians may refuse to order proce-
homes on to their children. Prior to this new law,         dures that are deemed to be medically futile, even
the marital home had been treated as off-limits to         though the patient or family may request the proce-
creditors or governments. A second measure allows          dures. Whether or not to proceed with “futile” treat-
the state to also tap decedents’ life insurance policies   ment often becomes an ethics decision to be decided
to recoup Medicare costs.                                  case by case. Some health care providers feel that
   Medicaid eligibility criteria and benefits vary         treatment of terminally ill patients may be consid-
from state to state. Medicaid does not cover PALLIA-       ered futile if the likelihood of success is 20 percent or
TIVE CARE as a separate benefit. Palliative care is        below. Most health care providers feel that treat-
available under the hospice benefit but only for           ment should be given only for the benefit of the
beneficiaries who have a prognosis of death within          patient and not for benefit of the family or health
six months and who agree to give up “curative              care practitioner, or based on cost. The patient’s cul-
treatment” for their terminal condition.                   ture and religion sometimes play a role in deter-
                                                           mining whether to initiate or continue with any
Higgins, Michelle. “Getting Poor on Purpose.” The Wall     given treatment that may be considered futile.
    Street Journal, February 25, 2003.                        Historically, the patients’ rights movement has
Tilly, Jane, and Joshua Wiener. “Medicaid and End-of-      focused on the right of an individual to refuse
    Life Care.” Washington, D.C.: The Urban Institute.     unwanted medical treatment. Recently, debates
    Available online. URL: http://www.lastacts.org/files/   about medical futility, treatment rationing, and
    publications/medicaid.pdf. Downloaded July 16, 2004.   managed care have caused patients’ rights advo-
                                                           cates to examine the flip side of patient autonomy—
                                                           the right to request treatment.
medical care at the end of life     See ADVANCE CARE          There are some ethicists and health care profes-
PLANNING.                                                  sionals who believe patient autonomy has gone too
                                                           far and should be limited. According to these pro-
                                                           fessionals, people should not have the right to
medical examiner A pathologist who has special             request treatment that is inappropriate or futile.
training in death investigation and legal autopsies,
who works for the government. A small city or rural
area may not have a medical examiner, and may              medical intervention       A diagnostic or treatment
rely solely on a CORONER. In some states or small          activity undertaken for the primary purpose of pre-
towns, the local doctor also functions as a medical        venting, improving, or stabilizing a medical condi-
examiner or coroner. Each state sets its own laws          tion. Activities that are primarily custodial, or part
regarding medical examiners; for example, medical          of normal existence, or undertaken primarily for
examiners in Virginia must investigate the following       the convenience of the patient, family or practi-
deaths: death by trauma or injury, by violence or          tioner, are not considered medical interventions.
poisoning, by accident, by suicide, by homicide,
sudden death when the decedent was in apparent
good health, sudden death as an apparent result of         medical power of attorney A legal document that
fire, and death unattended by a physician; death in         allows an individual to choose a person or persons
jail, prison, any correctional facility, police custody;   to be his or her proxy for medical decisions when he
alleged SUDDEN INFANT DEATH SYNDROME (SIDS) of a           or she becomes incapacitated.
child under 18 months; and any suspicious, unusual,           See also HEALTH CARE PROXY.
or unnatural manner of death.

                                                           Medicare A federal health insurance program
medical futility   Medical futility refers to interven-    administered by the Centers for Medicare & Medic-
tions that are unlikely to provide any real improve-       aid Services (CMS), formerly known as Health Care
ment in the patient’s overall condition, prognosis, or     Financing Agency, or HCFA, for people 65 years or
174 Medicare + Choice

older, certain people with disabilities under 65 years   quality hospice care regardless of which Medicare
of age, and people with end-stage renal disease (per-    program they select. Additional provisions to fur-
manent kidney failure requiring dialysis or a trans-     ther strengthen the services hospices provide to
plant)—the nation’s largest payer of care for the        dying Americans and their families include:
elderly. Medicare has two parts: Part A, which is
hospital insurance, and Part B, which is medical           Contracting Provisions, Section 946 Medicare-
insurance. End-of-life costs account for 27 percent of     certified hospices will be allowed to contract with
Medicare expenditures. According to the National           other Medicare-certified hospices for core serv-
Center for Policy Analysis (NCPA), Medicare aver-          ices. This will help hospices provide core services
ages the spending of $28,616 on medical bills for          when faced with situations such as more patients
seniors in their last two years of life. Currently,        than anticipated staffing shortages. The contract-
Medicare pays only for hospice care when a person          ing proposal will help hospices provide coverage
has six months or less to live. The Medicare Hospice       for traveling patients. This became effective upon
Benefit, originally enacted by Congress in 1982, has        enactment.
enabled more than 6 million Americans to receive           Nurse Practitioners, Section 408 Nurse practi-
high-quality end-of-life care through 2003.                tioners, not employed by a hospice, will be
    In 2002, national experts in end-of-life care          allowed to continue following their patients who
called unanimously for a major overhaul of Medi-           elect hospice care. This became effective upon
care’s payment structure for dying Americans. They         enactment.
pointed out that Medicare spends an immense
amount of money on expensive, painful, and futile          Hospice Educational Consultation, Section 512
life-prolonging care, while spending little for pain       Effective January 1, 2005, this allows for a one-
relief, quality of remaining life, and emotional sup-      time hospice consultation service for terminally
port for patients and their families. They also noted      ill Medicare beneficiaries. The service, which
that new evidence from some small-scale model              must be provided by a physician who is either
programs suggests that Medicare can deliver much           the hospice medical director or an employee of a
better care for dying Americans while not raising          hospice program, would involve an evaluation of
program costs. And, finally, they called for the fed-       the individual’s pain and symptom management
eral government to launch large-scale demonstra-           needs, counseling regarding end-of-life issues
tion programs within Medicare to determine                 and options for obtaining care, and advising the
whether findings from the smaller-scale studies hold        individual regarding advance care planning.
up when applied to the general population.                 A Rural Hospice Demonstration Project, Section
    On December 8, President George W. Bush signed         409 A CMS-developed project would establish
the Medicare Prescription Drug, Improvement and            three rural demonstration sites that would pro-
Modernization Act of 2003 into law. Although much          vide hospice care in residential facilities of 20 beds
debate surrounded this complex and extensive leg-          or less for beneficiaries who are unable to receive
islative reform, particularly related to prescription      hospice care in their home. The demonstration
drug coverage, the National Hospice and Palliative         sites would provide care inside the facility and
Care Organization pointed out that the Medicare            not in the community. This demonstration proj-
Hospice Benefit remained intact and was not altered.        ect would be conducted over a period of not more
Additionally, new provisions are included that will        than five years.
improve access to hospice.
    Designed to provide comprehensive coverage to
Medicare recipients who are terminally ill, the          Medicare + Choice      Medicare health plans offered
Medicare Hospice Benefit will continue to be treated      by private companies that contract with the
as a “carve out” for all Medicare programs, includ-      MEDICARE program. Such plans may provide bene-
ing the new Medicare Advantage program. This will        fits like coordination of care or reduction of out-of-
assure all Medicare beneficiaries access to high-        pocket expenses. Some plans may offer additional
                                                                                          memorial service 175

benefits, such as prescription drugs. There are two          day was expanded to honor those who have died in
types of Medicare + Choice plans available in many          all American wars. In 1971 Memorial Day was
parts of the country. To find a list of plans available      declared a national holiday by an act of Congress,
in any area, look at the Medicare Personal Plan             though it is still often called Decoration Day. It was
Finder at http://www.medicare.gov. In 2003, health          then placed on the last Monday in May. Many
insurers who provide Medicare + Choice plans                southern states also have their own days for honor-
announced that they would drop about 40,000 eld-            ing the Confederate dead.
erly and disabled members during 2004 because
government funding had not kept pace with rising
health care costs.                                          memorials      In the traditional sense, memorials are
                                                            objects or structures established in memory of a per-
                                                            son or event. Traditional forms of war memorials
Medigap insurance Also known as Medicare sup-               include statues, obelisks, triumphal arches, and other
plement insurance; private health insurance policies        commemorative structures, whose sole purpose is
that cover some of the costs not covered by the orig-       to serve as a memorial. Since World War II, such
inal MEDICARE plan. Medigap has 10 standard plans           structures have increasingly been giving way to “liv-
called Plan “A” through Plan “J,” each with a dif-          ing memorials”—useful projects such as community
ferent set of benefits. Medigap policies vary by state.      centers, libraries, forests, and even highways marked
                                                            in some fashion, usually with plaques, as memorials.
                                                                Impromptu memorials set up by strangers to
memento mori        See SYMBOLS OF DEATH.                   remember people who die as a result of tragedy are
                                                            a recent phenomenon and growing trend. Mont-
                                                            gomery writes that these are “physical and public
Memorial Day       On May 5, 1868, Maj. Gen. John           expressions of a community’s grief, whether the
A. Logan, head of an organization of Union veter-           community is a neighborhood or a nation. They’re
ans—the Grand Army of the Republic—established              most often built with flowers, photographs, and
Decoration Day as a time for the nation to decorate         candles. Some people have left balloons, greeting
the graves of the war dead with flowers and declared         cards and notes.” Psychologists consider this pub-
that it should be observed on May 30, a date when           lic expression of grief to be a meaningful way of
flowers would be in bloom across the country. The            responding to tragedy. Such spontaneous memori-
first large observance was held that year at ARLING-         als are powerful because they have the “spontane-
TON NATIONAL CEMETERY. Prior to this, local spring-         ity of raw, pure emotion,” according to Maya Lin,
time tributes to the Civil War dead had already been        who designed the Vietnam Veterans Memorial.
held in various places. Approximately 25 towns have
claimed connection with the origin of Memorial Day,         Newsweek. “The Art of Honoring the Dead.” Available
many of them in the South where most of the war               online. URL: http://msnbc.msn.com/id/3068030. Posted
dead were buried. In 1966, Congress and President             2002.
Lyndon Johnson declared Waterloo, New York, the             Montgomery, Christine. “Impromptu Memorials Salve
birthplace of Memorial Day. There, a ceremony on              Communal Grief: On-site Tributes the Trend as Pain,
May 5, 1866, honored local veterans who had                   Tragedy Hit Home.” The Washington Times, August 5, 1997.
fought in the Civil War. Businesses closed and resi-
dents flew flags at half-staff.
   By the end of the 19th century, Memorial Day             memorial service A ceremony commemorating
ceremonies were being held on May 30 throughout             the deceased, without the body present. Whereas
the nation. State legislatures passed proclamations         funerals center on the death and loss of a person,
designating the day. The army and navy adopted              memorial services emphasize the individual’s life.
regulations for proper observance at their facilities. It   Memorial services are commonly held by the family
was not until after World War I, however, that the          following BODY DONATION or tragedies where body
176 memorial society

retrieval is not possible. Also, memorial services are     with cooperating funeral homes to arrange set
sometimes held on anniversaries of deaths. Some            prices for members. They also make referrals to
families prefer a private church or graveside service      businesses offering price breaks on options such as
for immediate family, with a memorial service to           viewings, memorial services, scattering of ashes,
celebrate the life of the deceased held later at a         flowers, monuments, and cemetery plots. Tradi-
church or other public place that will accommodate         tionally, memorial society members have preferred
a wider circle of friends and colleagues. In many          cremation, but some now offer a choice of a simple,
religions, a memorial service is held following cre-       traditional funeral in place of cremation. Most
mation or at specified times following death. During        memorial societies prefer people to join in advance,
memorial services, the deceased is usually honored         but some accept enrollment of a deceased person by
through a celebration of his or her accomplishments,       family members after a death has occurred. As
often with specially selected poetry or music reflect-      many as 200 of these societies exist in the United
ing something of the person’s life or interests.           States and Canada (the numbers fluctuate because
   Today, many view a memorial service after cre-          they are volunteer run). Most charge a one-time
mation or quick burial as preferable to the standard       low membership fee.
funeral. Instead of having to deal with the myriad            Memorial societies originally organized as the
details of a larger funeral, the immediate family can      Continental Association of Funeral and Memorial
instead concentrate on the more pressing needs of          Societies, later became the Funeral and Memorial
body disposition and family decisions. Later—per-          Societies of America; currently, FUNERAL CONSUMERS
haps a week or even longer—friends, co-workers,            ALLIANCE is the umbrella organization. According
and out-of-town relatives can gather for a memorial        to Consumers’ Research Magazine, “These societies
service that serves many of the same functions of a        cooperate with funeral directors, sometimes by hav-
funeral, but relatively free of the time pressures of      ing actual contracts with them and sometimes by
the funeral. A memorial service can be held without        advising their members of some firms that provide
the funeral director—in a church, in the home, in a        inexpensive services. The societies can also assist in
park—often at a place of significance to the deceased.      making arrangements for donations and can offer
A memorial service generally involves less expense         information on legal requirements and death ben-
than a funeral, and can be held in a greater variety       efits. They do not arrange or direct funerals, pay
of locations.                                              for funerals, or choose a specific funeral director for
                                                           you.” Memorial societies have been at the center of
Funeral Consumers Alliance. “Planning a Memorial Ser-      efforts to assure consumer protection through both
  vice.” Available online. URL: http://www.funerals.org/   the Federal Trade Commission and state legislatures.
  personal/memorial.htm. Downloaded September 16,             Funeral Consumers Alliance maintains a listing
  2003.                                                    of member memorial societies searchable by state at
                                                           http://www.funerals.org/directry.htm.

memorial society A nonprofit, co-op member-                Castaneda, Laura. “Cutting the Cost of Funerals: Planning
ship organization that provides information about             Saves Money and Stress.” The San Francisco Chronicle,
funerals and body disposition, but is not part of the         January 13, 1997.
state-regulated funeral industry, thus does not offer      The Center for the Study of Services. “How to Cut Funeral
funeral services itself. Most often a memorial soci-          Costs.” Consumers’ Research Magazine 78, August 1,
ety is formed by a church or ministerial association,         1995: 24–27.
by labor, civic, or educational groups, or by con-
cerned individuals. Although some funeral homes
may include the word “society” in their names, they        men and grief      Grief can be particularly difficult
are not nonprofit organizations.                            for men who have been taught since childhood to
   Memorial societies are run by volunteers who            be strong, not to cry, and not to exhibit emotions
conduct local price surveys and negotiate discounts        lest they look like sissies. Because they tend to bot-
                                                                                    Middle Ages and death 177

tle up their feelings, men have been called the silent     • By making time to garden or be out in the natu-
grievers. In her book, What to Do When a Loved One           ral environment
Dies, Eva Shaw writes, “Because the grief is, at times,    • By keeping up good health through moderate
suppressed, it is never ‘processed’ and resolved.            exercise, good food, and plenty of sleep, and not
Some men grieve their entire lives.” Such unre-              consuming too much alcohol
solved grief has been suggested as one reason for the
higher death rate among widowers from suicide,             Shaw adds that traditionally men have thrown
accidents, strokes, and heart disease than among           themselves into their jobs following loss of loved
married men of the same ages. Both the inability to        ones, and, not having resolved their grief, often
express emotion and a reluctance to seek support           show aggression while driving or working with
inhibit men’s grief. The AARP Grief and Loss Pro-          tools and have little patience with coworkers or cus-
grams cautions, “Grieving men who bottle up their          tomers. Family, friends, and coworkers may with-
feelings may appear to others to be adjusting well.        draw when these men are “too busy” or “always so
Instead, they could be suffering alone, unable or          darned crabby,” yet their very busy-ness and crab-
unwilling to seek the support of friends, family, or       biness may be a crying out for help.
community groups.”
    Grief experts explain that how men grieve is sig-      AARP Grief and Loss Programs. “Men and Grief.” Avail-
nificantly linked to their expected role in society.          able online. URL: http://www.aarp.org/griefandloss/
Despite many changes in our society, it is still part of     men.html. Posted 2001.
a man’s role to do nearly all of the dangerous,            Golden, Thomas R. Swallowed by a Snake: The Gift of the
unhealthy, and life-threatening work. For example,           Masculine Side of Healing, Second Edition. Gaithersburg,
95 percent of deaths and permanent disabilities              Md.: Golden Healing Publishing, 2000.
from workplace injuries are male, according to the         Novant Health. “Understanding Grief.” Available online.
Novant Health Employee Assistance Program. Men               URL: http://www.novanthealth.org/eap/daily_issues/
are generally still expected to protect their wives,         grief_loss.jsp. Downloaded September 18, 2003.
children, and the community, which expectation
often inhibits any outward showing of grief. Novant
suggests the following ways in which grieving men          mercy killing     Often confused with ASSISTED SUI-
can help themselves:                                       CIDE,  mercy killing is the unrequested taking of
                                                           another’s life in order to save that person further
• By showing courage in allowing themselves to             suffering, according to Evans and Farberow. “Mercy
  experience the painful emotions of grief (rather         killing is usually an act of desperation and despair,
  than pushing them underground)                           and often the life-taker is on the verge of emotional
• By communicating clearly to others their need to         collapse from the stress that comes from caring for
  be alone and to deal with their feelings in private      and watching over a loved one who is terminally ill.
• By not shutting others out, but keeping commu-           Pushed to such limits, the life-taker at some point
  nication open in their relationships                     feels compelled to hasten death—by whatever
• By tuning in to their bodies (because feelings that      means—because no one else will.”
  have built up can often be discovered there and              See also EUTHANASIA.
  released into experience)
                                                           Evans, Glen, Norman L. Farberow, and Kennedy Associ-
• By consciously using rituals and activity through           ates. “assisted suicide,” in The Encyclopedia of Suicide,
  which to express and work with their grief                  Second Edition. New York: Facts On File, 2003.
• By slowing down and making time for being
  reflective and to connect with their grief (making
  time to grieve in order for there to be time to heal)    Middle Ages and death     The Middle Ages covered
• By staying close to reliable friends and talking to      the period in European history that followed the fall
  them                                                     of the Western Roman Empire (C.E. 476–600) and
178 midwifing a death

lasted into the 15th century or the beginning of the        Aiken, Lewis R. Dying, Death and Bereavement. Mahwah,
Italian Renaissance (historians variously place the            N.J.: Lawrence Erlbaum Associates, 2001.
end of the Middle Ages somewhere between 1453               Aries, Phillippe. Western Attitudes toward Death: From the
and 1500). Anxiety about death reached a peak in               Middle Ages to the Present. London: Marion Boyars Pub-
the Middle Ages, stimulated by numerous plagues,               lishers Ltd., 1994.
epidemics, wars, and the short life spans of this period.   DuBruck, Edelgard E., and Barbara I. Gusick, editors.
    During the Middle Ages, death and dying were               Death and Dying in the Middle Ages. New York: Peter Lang
more visible in the Western world than they are                Publishing, 1999.
today. Aiken notes that “publicly viewed execu-             Golden, Thomas R. Swallowed by a Snake: The Gift of the
tions, mortal skirmishes involving ordinary people,            Masculine Side of Healing, Second Edition. Gaithersburg,
and mass epidemics that claimed the lives of thou-             Md.: Golden Healing Publishing, 2000.
sands were common occurrences. No one knew
when death might strike or even if it might happen
before the day was over.”                                   midwifing a death       The process of guiding a per-
    Because people of the Middle Ages were so inti-         son through the dying process, utilizing massage,
mately connected with death, they tended to see it          touch, reminiscences, and other soothing tech-
as a natural course and conclusion of their life on         niques. It is a term frequently used by people who
this Earth. Great importance was placed on a man’s          prefer to have their loved ones die at home rather
knowing that he was about to die. Through outer             than in hospitals, where they feel they can better
signs or through intuitive inner knowing, the man           guide or “midwife” them through the passage to
became aware of his impending death and followed            the next life. According to Mortuary Management
prescribed ritual and behavior. Golden writes, “Men         (May 2000), San Francisco now has its own “Zen
(and women) had a sizable fear of sudden and                hospice,” which trains “professional death compan-
unexpected death because it would rob them of the           ions,” with its graduates called “midwives for
experience of their final ritual. There was a sense of       death.” In another context, “midwifing through the
pride that men had in being able to anticipate the          dying process” has also been used as a euphemism
time of their death. This was made somewhat eas-            for PHYSICIAN-ASSISTED SUICIDE.
ier by the lack of ‘good’ medical care. Most major ill-
nesses were fatal, and thus when someone became
severely ill it usually meant that they were dying.         military deaths Although military service is inher-
This made it somewhat easier to predict with some           ently stressful and at times dangerous, mortality
accuracy the time of approaching death.”                    rates among active duty military personnel are sig-
    People frequently organized final rituals in their       nificantly lower than those in the general U.S. pop-
own bedrooms. Aiken explains, “These rituals were           ulation, according to a 10-year National Center for
attended by family members, physicians, priests,            Health Statistics (NCHS) study. A Medical Surveil-
and perhaps legal representatives clustered around          lance Monthly Report notes that such a finding is
the bedside of the dying person. During these ritu-         not surprising because servicemembers are selected
als, which could last for days, grief was expressed,        for military service based on their past medical histo-
and personal, religious, and legal matters were dis-        ries and their health at the time of military induction.
cussed. This encouraged dying persons to put their          In addition, all servicemembers have free medical
worldly affairs in order so they could then die in          care—both preventive and curative—included as
peace with the knowledge that their last wishes             part of their benefits package. Also, those who
would be honored.”                                          develop life threatening medical conditions are likely
    During the late Middle Ages, the church became          to be discharged from active service prior to their
the unifying institution, leading to a tremendous           deaths (e.g., through medical disability retirement).
boom in religious discussion of death and the after-           The NCHS study found that from 1992 through
life. Also in the late Middle Ages, the human skele-        2001, 8,570 servicemembers died while on active
ton or a decayed corpse was used to personify death.        duty (overall mortality rate: 57.38 per 100,000 ser-
                                                                                                   miscarriage 179

vicemembers per year). Of the military services, the          those arrangements with DoD on behalf of family
air force had the lowest overall mortality rate (42.89        members.
per 100,000 per year) and the marines had the                    Although military funeral honors are a long-
highest (71.89 per 100,000 per year). During the              standing tradition, it was not until 1999 that the
surveillance period, mortality rates generally                rights of veterans and the responsibilities of the fed-
declined. The decline of mortality rates overall was          eral government were written into law. That law,
largely attributable to declines in each of the serv-         which took effect January 1, 2000, was the National
ices in accident-related deaths.                              Defense Act of 2000 (Public Law 106–65). Under
    More than half (53 percent) of all active duty            this new law, at a family’s request, every eligible vet-
deaths were attributable to accidents, and more               eran will receive military funeral honors, to include
than one-fourth of all deaths resulted from inten-            the presence of a military funeral honors detail,
tional acts (suicide, 20 percent; homicide, 6 per-            which will oversee folding and presenting the U.S.
cent; hostile action and terrorism, 1 percent).               flag and playing TAPS, either by a high-quality
Illnesses (18 percent) and undetermined/pending               recording or by a bugler. The law defines a military
circumstances accounted for the remainder.                    funeral honors detail as consisting of two or more
    Certain burial benefits or payments for survivors          uniformed military persons, with at least one being
are provided whether the in-service death is due to           a member of the veteran’s branch of military service.
combat, accident, or disease. The serviceperson’s                DoD provides an information kit to funeral direc-
immediate family qualifies for a $6,000 cash “death            tors to help them make arrangements. The same pro-
gratuity” to meet the immediate needs of the sur-             cedure for requesting military honors is followed
vivors. The government will reimburse a family                when burial is at a national cemetery. The Depart-
$6,900 for burial costs. A spouse and children qualify        ment of Veterans Affairs (VA) staff at national ceme-
for what’s called dependency and indemnity com-               teries will help, when necessary, to facilitate a request
pensation. A spouse receives a tax-free flat-rate annu-        to DoD for funeral honors at VA national cemeteries.
ity for life of $948 a month and dependent children              Veterans organizations may provide military
receive $237 per month, plus proceeds from any                funeral honors or may assist the military members
applicable life insurance, which most military mem-           rendering the honors. A few VA national cemeter-
bers carry at the highest level ($250,000). Some ben-         ies are served by veterans groups that regularly pro-
efits change or end if a surviving spouse remarries.           vide funeral honors.
    Burial benefits include a gravesite in any VA                The military funeral custom of firing three rifle
national cemetery with available space, the opening           volleys has been said to have its roots in supersti-
and closing of the grave, perpetual care of the grave         tion—to frighten evil spirits away from the grave.
at no cost to the family, a government headstone or           Another reason that’s been given is that it’s a recre-
marker, a burial flag, and a Presidential Memorial             ation of the act of firing three volleys to signal the
Certificate.                                                   end of a temporary truce called to allow each side to
    See also VETERANS BURIAL BENEFITS.                        clear its dead and wounded from the battlefield.
                                                                 See also VETERANS BURIAL BENEFITS.
Wilson, Abigail Garvey, and Marsha Lopez. “Mortality
   Trends among Active Duty Personnel, 1992–2001.”
   MSMR: Medical Surveillance Monthly Report 9, no. 1 (Jan-   miscarriage      The interruption or loss of any preg-
   uary 2003): 6–11.                                          nancy before the fetus is viable (capable of living). In
                                                              common usage, however, a spontaneous or natural
                                                              abortion is usually called a miscarriage, and the term
military funeral honors The Department of                     ABORTION is reserved for induced or elective abortion,
Defense (DoD) provides military funeral honors at             that is, the intentional termination of a pregnancy.
the burials of veterans. When requested, funeral
honors can be given at any cemetery—private or                Ammer, Christine. “abortion,” in The New A to Z of Women’s
government-operated. Most funeral directors make                Health, Fourth Edition. New York: Facts On File, 2000.
180 Mitford, Jessica

Mitford, Jessica (1917–1996)        A political rebel    pernicious than ever in its assault on American val-
and later journalistic muckraker who changed the         ues and wallets.
funeral industry. The daughter of the Second Baron          The American Way of Death Revisited (Random
Redesdale, Mitford was born in Burford, Oxford-          House, 1998) was published 35 years after the orig-
shire, England, in 1917. In 1939, she and her first       inal edition and contained new chapters on, among
husband, Esmond Romilly, a nephew of Winston             other things, prepayment (“Pay Now—Die Poorer”)
Churchill, immigrated to the United States. After        and the new multinational corporations (“A Global
the outbreak of World War II, Romilly joined the         Village of the Dead”), as well as a jaundiced look at
Canadian Air Force and was killed during a bomb-         the failure of the Federal Trade Commission to
ing raid. In 1943, Mitford married the radical lawyer    enforce the laws that the original edition of this
Robert Treuhaft, and they moved in 1948 to Oak-          book helped bring about.
land, California. As a trade union lawyer in Oak-
land, Treuhaft became aware of the financial
problems that deaths caused in working class fami-       molecular death The death of individual organs
lies. In an attempt to reduce the high costs of funer-   and tissues of the body after circulation ceases. Dif-
als, he established the Bay Area Funeral Society, a      ferent tissues die at different rates depending on
nonprofit undertaking service. In 1963 Treuhaft and       their oxygen requirements. Thus, within four min-
Mitford wrote together the best-selling book, The        utes of the blood supply to the brain ceasing, the
American Way of Death (1963). However, only Mit-         central nervous system is irreversibly damaged.
ford’s name appeared on the book cover as the pub-
lisher argued that “co-signed books never sell as
well as those with one author.”                          monument A tombstone or memorial of granite,
    In The American Way of Death, Mitford exposed        marble, or other natural stone that stands upright
the avarice and commercialism of the American            above the surface of the ground. In related context,
funeral industry at that time, demonstrating that        monuments have been defined as any structure,
death practices in the United States were among          statue, tombstone, building, tablet, or sign erected to
the most costly and elaborate in the world, and that     perpetuate or commemorate the memory of a per-
funeral expenses had been rising faster than the         son or persons, or an event.
general cost of living. Although bitterly denounced         See also GRAVE MARKER; MEMORIALS.
by the industry itself, the book was Mitford’s most
successful—partially because of the irony and wit
she employed to show in minute detail the many           morbidity     The number of cases of a particular dis-
unnecessary services the bereaved were sold at a         ease occurring in a single year per specified popula-
time of their greatest vulnerability, such as “practi-   tion unit. It may be calculated on the basis of age
cal” shoes for the corpse. Even though the funeral       groups, gender, occupation, or other population
industry attacked her ideas and her political history    group. Data for nationally notifiable diseases
in an attempt to discredit her in their fight against     reported to the Centers for Disease Control and Pre-
what they called the “Mitford syndrome,” the book        vention by the 50 states, New York City, the District
remained atop The New York Times best-seller list for    of Columbia, and the U.S. territories are collated
several months. Spurred by the public outcry             and published weekly in the Morbidity and Mortality
because of Mitford’s exposé, the funeral industry        Weekly Report.
did begin to reform its sales practices, and eventu-
ally the Federal Trade Commission set up the
FUNERAL RULE.                                            morgue A place to store bodies until they are
    At the time of her death, Mitford had nearly fin-     identified, autopsied, or transferred to a funeral
ished a complete revision of her long out-of-print       home for burial. Some hospitals and nursing homes
book with the intent of showing that, far from           have temporary morgues. In most states, the county
being reformed, the industry had become more             maintains a morgue, which may include an autopsy
                                                                                          mourning cards 181

suite, a separate forensics autopsy suite, a freezer for   emphasize the family’s grief and to augment the
long-term body storage, a refrigeration unit, and a        number of mourners. In Ancient Egypt, for exam-
special viewing room to allow police investigators,        ple, the wealthy might hire professional mourners,
state’s attorneys, and medical personnel involved          who were usually women, to walk in the funeral
in a case under investigation to view the autopsy.         procession—wailing, tearing at their hair, gnashing
                                                           their teeth, chanting dirges, and generally repre-
                                                           senting the sorrow of the family. In Victorian En-
moribund      Medical term to describe a patient who       gland, professional mourners were called “mutes”
is in a dying state; near death.                           and were hired to walk in the funeral procession,
                                                           looking suitably melancholy.

mortality statistics The ratio of deaths in an area
to the population of that area; expressed per 1,000        mourning      The process by which people adapt to a
per year. The Centers for Disease Control and Pre-         loss; a display of GRIEF as defined by one’s culture
vention (CDC) receives weekly mortality reports            and society. According to Doctor and Kahn, mourn-
from 122 cities and metropolitan areas in the United       ing practices may influence anxiety and even
States within two to three weeks from the date of          depression: “Mourning practices differ between cul-
death. These reports summarize the total number of         tures, and the process of grief influences the occur-
deaths occurring in these cities/areas each week.          rence of depression. For example, in some societies,
Data are published weekly in Table IV of the Mor-          religion promises continued interaction with the
bidity and Mortality Weekly Report. Knowing mortality      deceased and the possibility of reparation for what-
rates for diseases and other causes is important           ever wrong may have been done. However, accept-
because it helps set priorities for government-funded      ance of loss may be inhibited, if customary rites and
studies and legislative initiatives.                       beliefs lose significance in rapidly acculturating
                                                           groups. Whether mourning leads to depression
                                                           depends on the degree of ambivalence of the indi-
mortician     Another name for a FUNERAL DIRECTOR          vidual’s relationship to the lost person or object.
or UNDERTAKER. According to JESSICA MITFORD, writ-         Such relationships are affected by the interaction
ing in The American Way of Death Revisited (Knopf,         between parent and child, and particularly the rela-
1998), mortician as a replacement for undertaker           tionship of the father to child in patriarchal, tradi-
was first used in the trade journal Embalmers Monthly       tional societies, which differs from that in most
in its February 1895 issue, but was denounced in           Western cultures.”
such newspapers as the Chicago Times, which refused           See also MOURNING RITUALS AND CUSTOMS.
to use it in 1932, “not for lack of sympathy with the
ambition of undertakers to be well regarded, but           Doctor, Ronald M., and Ada P. Kahn. “cross-cultural
because of it. If they haven’t the sense to save them-       influences on anxiety,” in The Encyclopedia of Phobias,
selves from their own lexicographers, we shall not be        Fears, and Anxieties, Second Edition. New York: Facts
guilty of abetting them in their folly.”                     On File, 2000.



mortuary A building or room where dead bodies              mourning cards Also called memorial cards,
are kept before burial or cremation. Funeral homes         mourning cards were sent to family, friends, and
are mortuaries.                                            neighbors during the Victorian era to invite them to
                                                           the funeral; many were kept as remembrance keep-
                                                           sakes. According to Kerstens, a typical mourning
mourners, hired or professional Throughout his-            card of the period was black with gilt (gold leaf)
tory, various cultures have used professional              printing, and had a dove at the top holding a sign
mourners to participate in funeral rituals in order to     reading “In Loving Remembrance of.” In later years
182 mourning quilts

of the period, a mourning card might have had a              vidual’s overall grief experience if they are to pro-
photo of the deceased attached. Because mourning             vide culturally sensitive care to their patients. “In
cards included the deceased’s birth and death dates,         spite of legislation, health regulations, customs, and
historians and genealogists often use them to track          work rules that have greatly influenced how death
down official copies of birth and death certificates           is managed in the United States, bereavement prac-
and even obituaries. Kerstens writes, “Memorial              tices vary in profound ways depending on one’s cul-
cards, in their 4” × 6” cardstock format, went out of        tural background. When assessing an individual’s
vogue in the early part of the twentieth century.            response to the death of a loved one, clinicians
They can still be found today at wakes, containing           should identify and appreciate what is expected or
much the same types of information as their stur-            required by the person’s culture. Failing to carry
dier predecessors. However, modern memorial cards            out expected rituals can lead to an experience of
are smaller, are printed on paper, in color, and are         unresolved loss for family members. This is often a
sometimes laminated to be kept as a remembrance.”            daunting task when health care professionals serve
   See also VICTORIAN MOURNING DRESS.                        patients of many ethnicities.”
                                                                 Clements et al. note, “The cultural makeup of
Kerstens, Elizabeth Kelley. “Funeral Cards.” Ancestry Mag-   the United States continues to change rapidly, and
  azine 19, no. 5 (September/October 1999).                  as minority groups continue to grow, these groups’
                                                             beliefs and customs must be taken into account
                                                             when examining death, grief, and bereavement.”
mourning quilts      See QUILTS.                                 Mourning rituals have existed throughout his-
                                                             tory, evolving into current day customs. Early cul-
                                                             tural rituals included burial rituals to send the dead
mourning rituals and customs Rituals, such as                to their next home, vigils, face-painting, funeral
funerals, wakes, and prayers, help people deal               pyres, fasting, and wailing. The wearing of black dur-
with the grief that comes with the death of a loved          ing a full mourning period is not as customary today
one. Michalopoulou and Michalopoulou explain,                as it once was; men in mourning used to wear black
“Mourning rituals, which include emotional dis-              armbands and houses were draped in black crepe.
plays of grief and have a programmed mourning                    In Victorian England, according to Jupp and Git-
period, are said to limit excessive or pathological          tings, “Christian mourning rituals and the belief in
mourning. They provide a way for people to act and           family reunions in heaven helped to reconcile some
this restores a sense of order and continuity to their       parents to high infant and child mortality. Moreover,
lives, which enables the bereaved to adjust to the           the solace of the private and social memory of the
fact of death.”                                              dead was complemented by visible symbols of
    Each culture, religion, and social group has ways        remembrance such as paintings, photographs and
in which individuals convey that they have experi-           death masks of the deceased, and mourning jewelry.”
enced a loss. Different cultural customs, rituals, or            The Victorians’ strict and elaborate mourning rit-
rules for dealing with loss that are followed and            uals were enumerated in etiquette books, with each
influenced by one’s society are also a part of mourn-         community dictating how long the mourning period
ing. Yet Cowles, using six focus groups, each con-           would be, which varied according to the relationship
sisting of individuals from a specific culture, found         of the mourner to the deceased. Victorian mourning
that individual, intrapersonal experiences of grief          rituals included covering mirrors, hanging black
are similar across cultural boundaries. “This is true        wreaths on doors to announce their mourning, and
even considering the culturally distinct mourning            the sketching or painting of portraits of the corpses.
rituals, traditions, and behavioral expressions of               See also VICTORIAN MOURNING DRESS.
grief experienced by the participants.”
    The National Cancer Institute notes that health          Clements, P. T., et al. “Cultural Perspectives of Death,
care professionals need to understand the part that             Grief, and Bereavement.” Journal of Psychosocial Nursing
cultural mourning practices may play in an indi-                and Mental Health Services 41, no. 7 (July 2003): 18–26.
                                                                                  music therapy for the dying 183

Cowles, K. V. “Cultural Perspectives of Grief: An                organization in the world (according to their litera-
   Expanded Concept Analysis.” Journal of Advanced Nurs-         ture) offering mummification today, with arrange-
   ing 23, no. 2 (1996): 287–294.                                ments made through local funeral homes.
Jupp, Peter C., and Clare Gittings, editors. Death in England—
   An Illustrated History. Manchester, England: Manchester
   University Press, 1999.                                       music therapy for the dying        Therapy useful for
Michalopoulou, A. M., and E. Michalopoulou. “Social              managing symptoms of pain, anxiety, depression,
   Handling of Death.” ICUs and Nursing WEB Journal 12           and agitation, common in patients who know they
   (October–December 2002).                                      are dying. As early as the sixth century B.C.E.,
                                                                 Pythagoras, a Greek philosopher and mathemati-
                                                                 cian (ca. 582–500 B.C.E.), recognized the healing
mummification      Preservation of the body by dehy-             value of music. Modern musical therapy began in
dration of the tissues. Mummification can occur                  earnest in the 1950s, although even after World
naturally where the air is very dry, such as in a                War I, amateur and professional musicians visited
desert or inside a chimney. During the process, the              veterans hospitals throughout the country, playing
body tissues dry and shrivel, hardening into a leath-            for thousands of veterans suffering both physical
ery, parchmentlike mass of skin and tendons sur-                 and emotional trauma from the wars. This contin-
rounding the bone. During ideal conditions, the                  ued after World War II as well. The first music ther-
natural mummification process may take several                   apy degree program was founded at Michigan State
weeks.                                                           University in 1944. In 1998, the National Associa-
    Intentional mummification with the intent of                 tion for Music Therapy and the American Associa-
keeping the corpse as intact as possible, is usually             tion for Music Therapy joined to create the
associated with the Ancient Egyptians, but similar               American Music Therapy Association.
preservation of the dead was also practiced by                       Halstead and Roscoe explain, “Music is a useful
ancient Ethiopians, aboriginal inhabitants of the                therapeutic intervention that can improve quality of
Canary Islands, and by Peruvians 1,000 years prior               life for dying patients. Physiologic mechanisms in
to being conquered by Spain.                                     response to carefully chosen musical selections help
    According to the Egyptian State Information Ser-             to alleviate pain, anxiety, and nausea and induce
vice, Ancient Egyptians first practiced mummifica-                 sleep. Expression of feelings enhances mood. Music,
tion through natural means by laying the bodies in               a universal language, addresses individual and fam-
hot dry sands, which, with their sodium nitrates,                ily needs, thereby assisting patients to achieve a
slowed down the decomposition of the body. This                  peaceful death.” In fact, studies have shown that lis-
natural preservation of the body eventually led to               tening to music releases endorphins in the brain,
the development of mummification practiced by                    which blunt the feeling of pain and affect emo-
Egyptians of the dynastic period. However, mum-                  tions—promoting relaxation.
mification techniques did not fully develop until                    According to James Schaller, writing in the
the Fifth Dynasty when an elaborate cult of the                  American Pain Foundation’s newsletter, The Pain
dead was in full sway.                                           Community News, therapeutic music that reduces
    Today, modern mummification can be arranged                   pain and anxiety includes the following character-
through most funeral homes. Once the body is                     istics: instrumental, acoustic instruments, simple
mummified, it can be placed in a standard casket or               texture, slow to medium tempo, unfamiliar, and
sealed inside a mummiform—a metal container, gen-                limited dynamic range. This music should be played
erally made of bronze, shaped like a body, with the              softly alone or with other pain reduction modalities.
face of the person whose body it holds, called also a                Krout adds that music therapy can also be used
“life mask.” Mummification costs from $1,700 (par-                in the area of communication. “When loved ones
rot) to $28,000 (large dog) for pets and about                   are anticipating the patient’s impending death, they
$67,000 for humans. Summum, a nonprofit 501 (c)                   may find it difficult to express feelings, thoughts,
(3) organization in Salt Lake City, Utah, is the only            and last wishes. Music therapy is a service modality
184 Muslims

that can help to facilitate such communication                to this desire include concerns over difficulties in
between the family and the patient who is actively            receiving appropriate pastoral care, problems with
dying, while also providing a comforting presence.”           having relatives and friends present at the time of
Listening to favorite music can provide opportunity           death, and the wish to avoid a postmortem exami-
for the patient to reminisce and talk about his or her        nation. Irrespective of the place of death, almost all
fears about death and dying.                                  Muslims will wish for a prompt burial and any
   Practitioners of music thanatology provide musi-           attempts by doctors and members of their teams to
cal comfort, using harp, voice, and a special reper-          expedite the process of issuing a death certificate are
toire of music, at the bedside of patients near the           usually greatly appreciated.
end of life, following a practice developed by                   See also ISLAM AND DEATH.
Therese Schroeder-Sheker and the Chalice of
Repose Project, based in Missoula, Montana. Music-            Sheikh, A., and A. R. Gatrad, editors. Caring for Muslim
thanatology practitioners study for two years before            Patients. Oxford, U.K.: Radcliffe, 2000.
providing music vigils to help relieve the suffering of
dying patients around the world.
                                                              mythology of death Stories created by various
Anderson, J., et al. “Music to Be Born To, Music to Die       cultures that help people imagine what it will be like
    To.” British Medical Journal 321, no. 7276 (December      in the afterlife. Such stories are necessary, according
    23–30, 2000): 1577–1579.                                  to Collin Hughes, Washington State University,
Casura, Lily G. “A Quick Look at Music, Medicine, Death       because there is no way for those who have passed
    & Dying.” Townsend Letter for Doctors and Patients,       away to provide answers to people’s questions
    December 2002.                                            about death. “The shade or ghost or phantom or
Halstead, M. T., and S. T. Roscoe. “Restoring the Spirit at   spirit will, in many tales, wander around restlessly;
    the End of Life: Music as an Intervention for Oncology    mingle at times (in a kind of ethereal or psycholog-
    Nurses.” Clinical Journal of Oncology Nursing 6, no. 6    ical way) with the living.” Noting that the mythol-
    (November–December 2002): 332–336.                        ogy of death begins as a “call to adventure,” Hughes
Iler, John. “Soothing the Soul and Healing the Body with      explains, “The death of a loved one propels the hero
    Music.” Clinical Center News, National Institutes of      into an unknown realm, incites the journey, and
    Health, February 2003. Available online. URL: http://     eventually may lead a hero to a terrifying con-
    www.cc.nih.gov/about/news/newsletter/2003/feb03/          frontation. Heroes confront the ghosts of the past.
    index.html. Downloaded July 17, 2004.                     The journey takes place for a reason; so as to liber-
Krout, R. E. “Music Therapy with Imminently Dying Hos-        ate the hero from what haunts him or her. And in
    pice Patients and Their Families: Facilitating Release    turn the hero is revitalized and thus can return to
    near the Time of Death.” American Journal of Hospice &    revitalize the community in which he or she lives.”
    Palliative Care 20, no. 2 (March–April 2003): 129–134.
                                                              Hughes, Collin. “Mythology of Death.” Washington State
                                                                University. Available online. URL: http://www.wsu.edu/
Muslims  According to Sheikh and Gatrad, most                   ~hughesc/myth_of_death.html. Downloaded October
Muslims wish to die at home. Factors contributing               25, 2003.
                                                                                                                N
natal loss    Death of an infant through miscarriage,               ever, the identities of nearly half of the Union sol-
stillbirth, or immediately following birth. Jind                    diers buried in national cemeteries are unknown.
explored the post-traumatic effects among 110 par-                      Then in 1873, all honorably discharged veterans
ents who had suffered natal loss. One to four weeks                 became eligible for burial in national cemeteries.
post-loss, approximately half of the parents reported               New national cemeteries were established in the
that they were never or rarely concerned with                       1930s to serve veterans living in metropolitan areas
attributing responsibility for their baby’s death. The              such as New York, Baltimore, Minneapolis, San
importance of attributing responsibility was associ-                Diego, San Francisco, and San Antonio. In 1973,
ated with several post-traumatic symptoms, as was                   Congress transferred 82 national cemeteries from
searching for meaning in the death. Attributions to                 the Department of the Army to the Veterans Admin-
oneself, others, or God were positively and signifi-                 istration, now the U.S. Department of Veterans
cantly associated with numerous post-traumatic                      Affairs. Joining with 21 VA cemeteries located at
symptoms.                                                           hospitals and nursing homes, the National Ceme-
    See also FETAL DEATH; INFANT DEATH; MISCARRIAGE;                tery System, now the National Cemetery Adminis-
NEONATAL DEATH.                                                     tration (NCA), comprised 103 cemeteries after the
                                                                    transfer.
Jind, L. “Parents’ Adjustment to Late Abortion, Stillbirth              Today, the National Cemetery Administration is
   or Infant Death: The Role of Causal Attributions.” Scan-         responsible for 120 national cemeteries in 39 states
   dinavian Journal of Psychology 44, no. 4 (September              and Puerto Rico, as well as 33 soldiers’ lots and mon-
   2003): 383–394.                                                  ument sites, comprising nearly 14,000 acres. (Arling-
                                                                    ton National Cemetery and Soldiers Home National
                                                                    Cemetery are administered by the Department of
national cemeteries In the summer of 1862,                          the Army.) These national cemeteries are listed by
when thousands had already died in only the sec-                    state on the VA Web site at http://www.cem.va.gov/
ond year of the Civil War, Congress enacted legisla-                listcem.htm. More than 2.5 million Americans,
tion authorizing the president to purchase                          including veterans of every war and conflict since
“cemetery grounds” to be used as national ceme-                     the Revolutionary War are buried in the VA’s
teries “for soldiers who shall have died in the serv-               national cemeteries.
ice of the country.” Fourteen cemeteries were                           Generally speaking, veterans and members of
established that year. Soon after the war ended,                    the armed forces, World War II Merchant Mariners,
army crews scoured the countryside to locate the                    and spouses or unremarried surviving spouses and
remains of Union soldiers who died in battle. They                  dependents of eligible persons are eligible for burial
were reinterred with honor in national cemeteries.                  in a national cemetery. Eligibility for burial benefits
By 1870, the remains of nearly 300,000 Union dead                   can be obtained by calling a Veteran’s Benefits
had been buried in 73 national cemeteries. Most                     Counselor at (800) 827–1000.
were located in the Southeast, near the battlefields                     Burial benefits available include a gravesite in
and campgrounds of the Civil War. Tragically, how-                  any of the national cemeteries with available space,



                                                              185
186 National Funeral Directors Association

opening and closing of the grave, perpetual care, a     NFDA
government headstone or marker, a burial flag, and       13625 Bishop’s Drive
a Presidential Memorial Certificate, at no cost to the   Brookfield WI 53005
family. Cremated remains are buried or inurned in       (800) 228–6332 (toll free)
national cemeteries in the same manner and with         (262) 789–1880
the same honors as casketed remains.                    (262) 789–6977 (fax)
   However, national cemeteries are filling up          nfda@nfda.org
across the country as veterans from World War II        http://www.nfda.org
and the Korean War die at the rate of 1,800 a day.
By fall 2003, half of the 120 national cemeteries
were no longer open to new casket burials; 33 were      National Hospice and Palliative Care Organiza-
closed to all new burials except for family members     tion (NHPCO) The National Hospice and Pallia-
of veterans already buried there. Because of this, in   tive Care Organization is the oldest and largest
October 2003, Congress authorized six new               nonprofit membership organization representing
national cemeteries in Philadelphia; Birmingham,        almost 80 percent of America’s hospice and pallia-
Ala.; Bakersfield, Calif.; Greenville/Columbia, S.C.;    tive care programs. NHPCO’s mission is to improve
and in Jacksonville and Sarasota, Florida. Five oth-    end-of-life care and expand access to hospice,
ers—in Atlanta, Detroit, Pittsburgh, West Palm          thereby enhancing quality of life for dying Ameri-
Beach, and Sacramento—were scheduled to open            cans and their loved ones. In 2002, NHPCO esti-
by 2005.                                                mated that more than 885,000 patients were served
   See also VETERANS BURIAL BENEFITS.                   by the nation’s approximately 3,200 hospices.
                                                           The National Hospice and Palliative Care Organi-
                                                        zation, founded in 1978 as the National Hospice
National Funeral Directors Association (NFDA)           Organization, changed its name in February 2000.
Founded in 1882, the National Funeral Directors         With headquarters in Alexandria, Virginia, the
Association is the oldest, largest, and most influen-    organization advocates for the terminally ill and
tial funeral trade association in the world. Its mis-   their families. It also develops public and profes-
sion is to provide advocacy, education, information,    sional educational programs and materials to
products, programs, and services to help members        enhance understanding and availability of hospice
enhance the quality of service to families—while        and palliative care; convenes frequent meetings and
growing successful businesses. As JESSICA MITFORD       symposia on emerging issues; provides technical
wrote in The American Way of Death Revisited, the       informational resources to its membership; conducts
NFDA “serves its affiliated state groups through        research; monitors congressional and regulatory
bulletins, keeping watch on legislative develop-        activities; and works closely with other organiza-
ments, lobbying activities, advising member firms        tions that share an interest in end of life care. The
on methods of cost accounting, and other business       NHPCO toll-free Help line—(800) 658–8898—pro-
procedures.” The FDA also monitors industry sta-        vides free consumer information on hospice care
tistics, on which it reports more than 21,757           and puts the public in direct contact with hospice
funeral homes in the United States, employing           programs. For more information contact:
approximately 34,500 licensed funeral directors/
embalmers, and 69,000 additional funeral service        National Hospice & Palliative Care Organization
and crematory personnel. Of the 2,404,000 deaths        1700 Diagonal Road
in the United States during 2000, approximately         Suite 625
75 percent resulted in earth burial or entombment       Alexandria, VA 22314
and 25 percent resulted in cremation. The average       (703) 837–1500
cost of a funeral from NFDA’s 2001 General Price        (703) 837–1233 (fax)
List survey was $5,180 for an adult funeral. For more   nhpco_info@nhpco.org
information contact:                                    http://www.nhpco.org
                                                                                         natural disasters 187

Native American Grave Protection and Repatria-            • Unassociated funerary objects: 77,587 (includes
tion Act (NAGPRA) Enacted in 1990 by Con-                   many small items, such as beads)
gress, NAGPRA legislation addresses the rights of         • Sacred objects: 1,185
Native American tribes to archaeological artifacts
                                                          • Objects of cultural patrimony: 267
housed in museums, university collections, or
within federal agencies. The legislation requires         • Objects that are both sacred and patrimonial: 644
government agencies and universities to inventory
any human remains and/or cultural objects that            However, in early 2004, less than one-fifth of the
relate to recognized Native American tribes. The          Smithsonian Museum of Natural History’s original
tribes then must be consulted regarding return or         collection of 18,000 remains had been returned,
reburial of the objects.                                  and another 90,833 sets of remains in America’s
   NAGPRA provides a process for the return of cer-       other museums lacked sufficient documentation to
tain Native American cultural items—human                 ensure their return in the foreseeable future. Not
remains, funerary objects, sacred objects, or objects     only does the repatriating of remains often take
of cultural patrimony—to lineal descendants, and          years of scientific study to determine their origins,
culturally affiliated Indian tribes and Native Hawai-      but some Native American groups do not want the
ian organizations. The act also includes provisions       remains while others are involved in disputes over
for unclaimed and culturally unidentifiable Native         ownership among themselves.
American cultural items, intentional and inadver-            See also REBURIAL.
tent discovery of Native American cultural items on
federal and tribal lands, and penalties for noncom-
pliance and illegal trafficking. In addition, NAGPRA       natural death       Pathologists refer to a death as
authorizes federal grants to Indian tribes, Native        “natural” when it results from a spontaneous or
Hawaiian organizations, and museums to assist with        naturally occurring disease or degenerative process,
the documentation and repatriation of Native              as distinct from a death that results from accident or
American cultural items.                                  violence. Proponents of palliative care talk about
   Although museums and federal agencies are              ways to allow for a natural death as opposed to
required to keep their own record of repatriations,       “resuscitating” or “providing feeding tubes” to keep
NAGPRA does not require reporting of repatriations        a patient alive. Still others refer to a natural death as
to the secretary of the interior or to the National       one where the death is orderly and peaceful, with
Park Service. Museums and federal agencies are            no violence and no mess. Then “The Natural Death
required, however, to publish notices in the Federal      Centre,” a charitable project launched in Britain in
Register when they have determined that Native            1991, supports those dying at home and their care-
American human remains, funerary objects, sacred          givers and helps people to arrange inexpensive, do-
objects, and/or objects of cultural patrimony are         it-yourself, and environmentally-friendly funerals.
culturally affiliated and are eligible for repatriation.
The national NAGPRA program compiles statistics
twice yearly on the total number of Native Ameri-         natural disasters     According to World Disasters
can human remains, funerary objects, sacred               Report 2003, more natural disasters were reported in
objects, and cultural objects for which Federal Reg-      2002 than in any year of the preceding decade.
ister notices have been published. Statistics             Fortunately, 2002’s disasters appeared less deadly
announced in 2003 of Native American human                than before—24,500 people were reported killed,
remains and cultural items repatriated since the pas-     compared to the decade’s average of 62,000 per
sage of NAGPRA included                                   year. These figures do not even include data on
                                                          those killed or affected by war and conflict-related
• Human remains: 27,777 individuals                       famine or disease. Disasters can be most devastat-
• Associated funerary objects: 558,799 (includes          ing in the world’s poorest and least developed
  many small items, such as beads)                        countries. Of those killed in 2002, just 6 percent
188 near death experiences

lived in countries of high human development                  Simpson writes, “The occurrence of near death
(HHD). While countries of low human develop-              experiences is not an innovative subject. Parallels
ment (LHD) reported the fewest natural disasters          have existed as early as the Bible and Plato’s Repub-
during the decade, their death toll is by far the         lic. The NDE was given further consideration in
highest. When related to the number of reported           1975 by Dr. Raymond Moody who initiated an
disasters, an average of 555 people died per disas-       interest from the general public and researchers
ter in LHD nations, compared to 133 in countries          alike, with his book Life after Life.” Simpson con-
of medium human development and 18 people in              cludes that the number of people who have claimed
HHD nations.                                              to have an NDE is “phenomenal and overwhelming.
   Across the decade, famine remained by far the          In addition, the numbers of those who have expe-
deadliest disaster, killing at least 275,000 people       rienced this phenomenon may be underestimated
(nearly half of all reported fatalities). Comparing       because of the persons’ feeling of insecurity in talk-
the decades 1983–92 and 1993–2002, reported               ing with others about their paranormal incident.”
global deaths from natural and technological disas-       Therefore, she concludes, “It is vital that nurses
ters have fallen by 38 percent.                           become aware of the NDE and how to support the
                                                          client who has had the experience.”
Walter, Jonathan, editor. World Disasters Report 2003.        Explaining that NDEs share some features with
  Bloomfield, Conn.: Kumarian Press, 2003.                 the phenomenon of dissociation, in which a per-
                                                          son’s self-identity becomes detached from bodily
                                                          sensation, Greyson explored the frequency of dis-
near death experiences (NDE)             Many people      sociative symptoms in people who had come close
who have come close to death have reported hav-           to death. “People who reported NDEs also reported
ing an “experience” or “happening” while they             significantly more dissociative symptoms than did
were outside of normal consciousness. A U.S. News         the comparison group. Among those who reported
and World Report poll found that of the 18 percent of     NDEs, the depth of the experience was positively
Americans who claimed that they had been on the           correlated with dissociative symptoms, although the
verge of dying, about one-third, or some 15 million,      level of symptoms was substantially lower than that
reported an NDE. White describes several of these         of patients with pathological dissociative disorders.
reported near death experiences: “People say they         The pattern of dissociative symptoms reported by
traveled through a tunnel, saw a shining light and        people who have had NDEs is consistent with a
were overcome with a feeling of serenity, only to be      non-pathological dissociative response to stress, and
snatched back to mortal life.” Others have described      not with a psychiatric disorder. A greater under-
NDEs as leaving one’s body and hovering overhead          standing of the mechanism of dissociation may shed
while being aware of what’s going on below, or            further light on near-death and other mystical or
meeting deceased family members, or seeing one’s          transcendental experiences.”
past life flash by.                                            According to Bartholomew, recent medical
   Roy and Russell note, “Individuals who have            advances that allow doctors to resuscitate people
recovered after reaching a state of clinical death com-   who previously would have been irretrievably dead
monly report a pleasant psychological state of emo-       have contributed to the increased reporting of
tional warmth, being in the presence of loved ones,       NDEs. She notes that initially doctors dismissed such
and sometimes seeing God or a godlike figure.”            reports as “hallucination, brought on by changes in
Indeed, some who have undergone such an experi-           the dying brain.” However, she says, the paradox
ence have likened it to a religious experience,           that these perceptions “occur during NDEs when
believing that it proves there is a life after death.     there is no functioning brain through which to
Others, particularly those in the scientific commu-        receive them”—such as when brain surgery patients
nity, believe these experiences can be explained by       have been brought to a “standstill”—has scientists
the chemical changes taking place in the brain at         “groping for answers.” Among the possibilities:
times of trauma or closeness to death.                    Consciousness may not reside solely in the brain.
                                                                                                    necrophobia 189

Bartholomew, Anita. “After Life: The Scientific Case for the   do before dying. Among the ways hospice suggests
   Human Soul.” Reader’s Digest (August 2003): 122–128.       that families can help the dying person ease through
Greyson, B. “Dissociation in People Who Have Near-Death       this transition are to:
   Experiences: Out of Their Bodies or Out of Their
   Minds?” Lancet 355, no. 9202 (February 5, 2000):           • Go along with the patient’s meanderings and
   460–463.                                                     thoughts rather than contradicting or putting
Roy, F. Hampton, and Charles Russell. “Attitudes toward         down what he or she says. These experiences can
   Death among the Elderly,” in The Encyclopedia of Aging       be very comforting to the patient.
   and the Elderly. New York: Facts On File, 1992.            • Be there. Simply sit with the person and be open
Simpson, Suzanne M. “Near Death Experience: A Concept           to his or her attempts to communicate.
   Analysis as Applied to Nursing.” Journal of Advanced
                                                              • Listen attentively and sensitively and acknowl-
   Nursing 36, no. 4 (November 2001): 520–526.
                                                                edge the experiences.
White, Gayle. “Living with Death.” The Atlanta Journal
   and Constitution, April 11, 1998.                          • Ask gentle questions about what your loved one
                                                                is saying or doing, such as, “Who do you see?”
                                                                “What are you seeing?” and “How does that make
nearing death awareness        Term coined by Calla-            you feel?”
han and Kelly, hospice nurses, in their now classic           • Allow the person to share this experience with you.
book, Final Gifts, to describe an altered state of con-
sciousness entered by a dying person, in which the            Callahan, Maggie, and Patricia Kelly. Final Gifts; Under-
person drifts between both worlds. Most patients                 standing the Special Awareness Needs and Communications
who have signs of nearing death awareness are more               of the Dying. New York: Bantam, 1997 (reprint).
peaceful after the experience. According to the Hos-
pice of the Florida Sun Coast, people who are expe-
riencing signs of nearing death awareness may:                necrophilia An irresistible sexual attraction to or
                                                              erotic interest in dead bodies. In their review of 122
• Appear confused and disoriented                             cases with evidence of necrophilic acts or fantasies,
• State that they have spoken to those who have               Rosman and Resnick distinguish genuine necrophilia
  already died                                                from pseudonecrophilia, and classify true necrophilia
                                                              into three types: necrophilic homicide, “regular”
• Speak to people and see places not visible to you
                                                              necrophilia, and necrophilic fantasy. “Neither psy-
• Describe spiritual beings and bright lights                 chosis, mental retardation, nor sadism appears to be
• Talk aloud to people who have died before them,             inherent in necrophilia. The most common motive
  such as their mother, father, or close friend               for necrophilia is possession of an unresisting and
• Make “out of character” statements, gestures, or            unrejecting partner. Necrophiles often choose occu-
  requests                                                    pations that put them in contact with corpses. Some
                                                              necrophiles who had occupational access to corpses
• Describe another world of peace and beauty
                                                              committed homicide nevertheless.”
• Tell you exactly when they will die
• Make hand gestures, reach for or hold unseen                Rosman, J. P., and P. J. Resnick. “Sexual Attraction to
  objects, or wave to unseen beings                             Corpses: A Psychiatric Review of Necrophilia.” The Bul-
                                                                letin of the American Academy of Psychiatry and the Law 17,
Family witnessing these behaviors sometimes                     no. 2 (1989): 153–163.
express concern that their loved one is confused or
even hallucinating, but hospice caregivers believe
the person is simply beginning to transition from             necrophobia    A persistent and irrational fear of
this life. The person may be trying to describe the           dead bodies. According to Doctor and Kahn, “Indi-
dying experience or something he or she needs to              viduals who fear looking at dead bodies (human or
190 neocortical death

animal) may indirectly fear that they will also die or          death is birth defects, which cause about 25 percent
that there may be some ‘contagion.’ Some necro-                 of neonatal deaths. Prematurity and its complica-
phobes may also be fearful of disease or injury. This           tions cause about 20 percent of neonatal deaths.
fear extends to looking at cadavers and carcasses of            The earlier a baby is born, the more likely he or she
animals. Fear of corpses may be related to a fear of            is to die. Only 5 to 10 percent of babies born at 23
death, and many individuals who fear viewing a                  weeks of pregnancy survive, while about 50 percent
corpse also fear going into a cemetery, looking at              of babies born at 24 weeks and 80 percent born at
tombstones, or even attending a funeral.”                       26 weeks survive. Less common causes of neonatal
                                                                death include problems related to complications of
Doctor, Ronald M., and Ada P. Kahn. The Encyclopedia of         pregnancy; complications involving the placenta,
  Phobias, Fears, and Anxieties, Second Edition. New York:      cord, and membranes; infections; and asphyxia
  Facts On File, 2000.                                          (lack of oxygen before or during birth).

                                                                March of Dimes, “Neonatal Death Fact Sheet.” March
neocortical death      A form of brain death resulting            of Dimes. Available online. URL: http://www.
in the loss of all of the mental functions that make              marchofdimes.com/professionals/681_1196.asp.
us fully human beings; a person can be kept in a                  Posted 2003.
vegetative state indefinitely after this has occurred.

Volti, Rudi. “brain death,” in The Facts On File Encyclopedia   next of kin     A person’s closest living relative or
   of Science, Technology, and Society. New York: Facts On      relatives; by legal definition, in a descending order
   File, 1999.                                                  of priority: spouse; adult son or daughter; either
                                                                parent; adult brother or sister; legal guardian; any
                                                                other explicitly authorized person. Grief therapist
neonatal death Death of a live-born infant within               and death educator Barbara J. Paul writes, “For the
the first 28 days of life. Previous generations were             parents of a married son or daughter, it is often a
more accustomed to infant and neo-natal deaths,                 shock for them to realize that they are not legally
when half or more of newborns might die. Women                  the next of kin. All decision-making power is tech-
born in the first quarter of the 20th century consid-            nically in the hands of the spouse.”
ered it unlucky to buy baby clothes or furnish nurs-
eries until a baby was born and established as                  Paul, Barbara J. “Losing a Son or Daughter.” AARP Grief
healthy. This was not merely a superstition, but also              and Loss Programs. Available online. URL: http://www.
a psychological defense against the disappointment                 aarp.org/griefandloss/articles/16_a.html. Downloaded
and grief of losing a newborn, compounded by the                   November 13, 2003.
visual evidence of the hoped-for child right there in
the home. The success of neonatal care over the
past 20 years has diminished most of these appre-               niche    Also called a memorial niche. A space in a
hensions. In 1983, the U.S. neonatal mortality rate             COLUMBARIUM, MAUSOLEUM, or niche wall to hold an
for all mothers was 7.1 per 1,000 live births; in               URN. Many cemeteries now offer niche space in a
2001, it was 4.5. The highest neonatal death rate is            variety of settings, and some funeral homes also
among black or African American (not Hispanic or                now offer niche space. Niche space may be selected
Latino) mothers (9.0 in 2001); the lowest is among              for the placement of an individual urn or as a com-
Asian or Pacific Islander mothers (3.1 in 2001).                panion space for multiple urns. Niche fronts are
Other 2001 neonatal death rates: Hispanic or                    constructed using clear or stained glass, bronze,
Latino, 3.6; white (not Hispanic or Latino), 3.8;               marble, granite, or wood. Some niche fronts are
American Indian/Alaska Native, 4.2.                             part of a mosaic wall. Glass-front niches allow for
   According to the March of Dimes Birth Defects                personalization through the placement of photo-
Foundation, the most common cause of neonatal                   graphs and mementos with the urn.
                                                                                             nursing homes 191

nondisclosure     Not telling a dying patient that he or      nursing homes      As the American population ages,
she is indeed dying. Although American medical                nursing homes are becoming the most frequent site
ethics now generally call for truth telling, our increas-     of death. According to the National Center for
ingly diverse culture is complicating the issue for           Health Statistics, in 1997 more than 20 percent of
physicians. Cochella and Pedersen note, “Surveys              the aged died in nursing homes. That figure is
show that many ethnic and Native Americans would              expected to reach 40 percent by 2020. Other stud-
not want to be told distressing news about their              ies have shown that 70 percent of those who die in
health. As a result, our bias in favor of truth-telling       nursing homes are women; and the older people
risks alienating these patients and their families.”          are, the more likely they are to die in nursing
   When the patient is a child or young adult,                homes. According to a 1993 study, 20 percent of
knowing all hope is lost can be especially difficult to        whites, 22 percent of Mexican Americans, and 14
handle. One argument for nondisclosure in such                percent of blacks die in nursing homes.
cases is: “Once they know everything there is no                 Yet nursing homes score even worse than hospi-
way of taking back that knowledge . . . it is some-           tals in polls about where patients would prefer to
thing that they will always know and be thinking              die. The largest clinical study ever conducted in the
about on some level every day until they pass                 United States on decision-making at the end of life
away.” On the other hand, Sahler et al. write,                showed that almost a third of the patients would
“Nondisclosure leads to feelings of isolation and             rather die than live in a nursing home. An addi-
abandonment in the patient. Because there is a                tional third (37 percent) would be either “very
‘secret’ that everyone knows but the child, it                unwilling” or “somewhat unwilling” to live in a
becomes impossible to have honest discussions                 nursing home. Only one-quarter the participants
about hope, sadness, fear, or separation. In trying to        (26 percent) indicated any willingness at all.
avoid a moment of exquisite but relatively brief dis-            Jarvik and Collins write, “Like other parts of the
comfort that the physician might experience if the            health care system, nursing homes have begun to
child becomes disconsolate, the physician actually            re-think how people live and die in their facilities.
risks depriving himself or herself of experiencing            The good nursing homes, say the people who study
the personal and professional satisfaction of doing           them, provide the essentials of end-of-life care:
everything, including providing profound comfort.”            attention from people who have grown to love
   Legal liability is also a concern for physicians           you, who care that you are comfortable, who work
when the family of a terminal patient requests                to help you keep your dignity and self-worth until
nondisclosure, but Cochella and Pedersen write,               the end. When a cure is not possible, they move
“U.S. law and our judicial system’s application of it         beyond that to palliative care, controlling pain and
suggest that, in the appropriate context, physicians          symptoms while providing emotional and spiritual
are not liable for choosing nondisclosure.”                   support.”
                                                                 It is worth noting the differences between nurs-
Cochella, Susan E. W., and Donald M. Pedersen. “Negoti-       ing homes and other long-term care facilities, which
   ating a Request for Nondisclosure.” American Family        are sometime confused with nursing homes.
   Physician 67, no. 1 (January 1, 2003): 209–211.
Girgis, A., and R. W. Sanson-Fisher. “Breaking Bad News:        Nursing homes Facilities licensed by the state
   Consensus Guidelines for Medical Practitioners.” Jour-       that provide 24-hour nursing care, room and
   nal of Clinical Oncology 13, no. 9 (1995): 2449–2456.        board, and activities for convalescent residents
Krisman-Scott, Mary Ann. “An Historical Analysis of Dis-        and those with chronic and/or long-term care
   closure of Terminal Status.” Journal of Nursing Scholar-     illnesses. One step below hospital acute care.
   ship 32, no. 1 (2000): 47–52.                                Regular medical supervision and rehabilitation
Sahler, Olle Jane, et al. “Medical Education about End-of-      therapy are mandated to be available, and nurs-
   Life Care in the Pediatric Setting: Principles, Chal-        ing homes are eligible to participate in the Med-
   lenges, and Opportunities.” Pediatrics 105, no. 3, pt. 1     icaid program. May be referred to as skilled
   (March 2000): 575–584.                                       nursing facility or convalescent home.
192 nursing homes

  Independent living centers Multi-unit senior              Memory care centers are most likely to be