 
## Anticipating Death:

THE EXPERIENCE OF ANTICIPATING DEATH OF SELF

IN HEALTHY LATER LIFE

by

Jennifer B. Ghent-Fuller, RN, BA, BScN, MScN
Copyright 1996 by Jennifer Ghent-Fuller.

Smashwords Edition 2014

ISBN 978-0-9881678-4-1

License Notes: Thank you for downloading this book. You are welcome to share it with your friends. This book may be reproduced, copied and distributed for non-commercial purposes, providing the book remains in complete original form. Small sections may be quoted by other authors with attribution. Other books by this author are available at your favourite retailer.

This book was submitted as a thesis in partial fulfillment of the requirements for the degree of Master of Science in Nursing, Faculty of Graduate Studies, The University of Western Ontario, London, Ontario, Canada, September 1996.
NOTE CONCERNING THIS EDITION (2014)

In order to make this work suitable for any audience, some changes in the order have been made since it was first published in 1996 in hard copy as a Master's Thesis. The chapter on 'Findings' has been moved so it is immediately after the 'Table of Contents' and 'Abstract'. The 'Certificate of Examination', 'Dedication', 'Acknowledgements', 'List of Appendices' and 'List of Figures' have been moved from the beginning to near the end. The contents of the former 'Appendix G: Additional Supportive Quotes' have been distributed into the relevant sections of the first chapter on 'Findings.' The 'Vita' section has been replaced by a section entitled 'About the Author.' Otherwise, the text of the original Master's Thesis is unchanged.
ABSTRACT

The purpose of this study was to illuminate insights of the anticipation of death of self in healthy later life, in order to enhance nurses' understanding of older clients. An interpretive phenomenological methodology was used to gather and analyze interview data from a purposefully selected sample of four male and four female older adults. Findings describe the participants' experience of the anticipation of death of self in later life as an on-going process of "creating readiness" and "achieving purpose" related to their future death. Participants both reflected and projected their thoughts and activities in five "spheres of being": "internal being"; "existence in the world as a solitary being"; "relationships with other individuals"; "existence in the world as a part of humankind"; and "existence after death". The growing proportion of the population which is aged is increasingly older and in need of health care, and furthermore, is being asked to do advance planning for death. In order for health professionals to assist and support older persons undertaking this and other challenges of aging, a deeper understanding of the issue of anticipation of death of self for older clients is necessary.
TABLE OF CONTENTS

ABSTRACT

CHAPTER ONE - FINDINGS

1. The Nature of Reflecting and Projecting

2. The Spheres of Being

3. Creating Readiness

(a) Creating Readiness in the Internal Sphere

(i) Accepting the Inevitability of Death

(ii) Identifying Satisfaction with Life

(iii) Preparing for Death

(iv) Acknowledging Concerns for Future Personal Condition

(v) Responding to Concerns

(b) Creating Readiness in the Sphere of Existence in the Physical World as a Solitary Being

(c) Creating Readiness in the Sphere of Relationships with other Individuals

(i) Perceiving the Impact on Relationships

(ii) Communicating Within Relationships about Creating Readiness

(iii) Anticipating Comforts from Relationships at the Point of Dying

(d) Creating Readiness in the Sphere of Existence in the World as a Part of Humankind

(e) Creating Readiness in the Sphere of Existence after Death

4. Achieving Purpose

(a) Achieving Purpose in the Internal Sphere

(b) Achieving Purpose in the Sphere of Existence in the World as a Solitary Being

(c) Achieving Purpose in the Sphere of Relationships

(d) Achieving Purpose in the Sphere of Existence in the World as a Part of Humankind

(e) Achieving Purpose in the Sphere of Existence after Death

5. The Holistic Experience of Anticipating Death of Self in Healthy Later Life

6. Summary

CHAPTER TWO - OUTLINE OF THE PROBLEM

1. Background and Significance

2. Statement of the Problem

3. Study Purpose

4. Research Question

CHAPTER THREE - LITERATURE REVIEW

1. Earliest Work

2. Study of the Contemplation of Death as Abnormal Thought

3. Study of the Contemplation of Death as Anxiety or Fear

4. Studies Relating Level of Death Anxiety to Other Attitudes or Personality Characteristics

5. Study of Contemplation of Death as Disinterest

6. Contemplation of Death as Awareness of Finitude

7. Death as Defined by the Individual

8. Summary

CHAPTER FOUR - METHODOLOGY

1. Overview of the Methodology

2. Sampling

3. Data Collection Method

4. Analysis and Interpretation

5. Protection of Human Rights

6. Declaration of Self in Front of the Text

7. Validity and Trustworthiness

8. Summary

CHAPTER FIVE - DISCUSSION

1. Relation of the Findings to Previous Literature on the Anticipation of Death in Healthy Later Life

2. Implications for Nursing Education

3. Implications for Nursing Practice

4. Implications for Future Research

5. Conclusion

APPENDIX A: Letter of Information

APPENDIX B: Letter of Introduction

APPENDIX C: Notice of Participation Decision

APPENDIX D: General Interview Guide

APPENDIX E: Personal History Sheet

APPENDIX F: Certificate of Approval of Human Research

APPENDIX G: Certificate of Examination

REFERENCES

DEDICATION

ACKNOWLEDGEMENTS

ABOUT THE AUTHOR

Figure 1:The Anticipation of Death of Self in Healthy Later Life: Creating Readiness and Achieving Purpose in the Context of Five Spheres of Being

CHAPTER ONE: FINDINGS

The healthy older adults in this study were in the process of integrating the experience of anticipating their future death into their concept of self. Two major process themes encompassed the experience of integrating anticipated future death into self-concept: "creating readiness" and "achieving purpose". The experience of anticipating future death was portrayed in five different spheres of being. These five spheres of being were: their internal being; their existence in the physical world as solitary beings; their relationships with other individuals; their existence in the world as part of humankind; and their existence after death.

This chapter outlines the experience of the participants as they portrayed it and describes how experience of anticipation of death of self is best understood through integration of the process themes of creating readiness and achieving purpose throughout five spheres of being. The five spheres of being represent different mental projections of the self into the world, and the final mental projection of the self out of the world. Quotations from the interviews were included to illustrate the themes. Additional supportive quotes are found at the end of most sections.

1. The Nature of Reflecting and Projecting

The nature of reflecting on the thoughts of their own future death, or future non-existence in the sphere of internal life, was described by three participants as often being fleeting, or flashing:

It's a fleeting thought that goes through your mind, that I don't have as many years to life, life is shorter, I don't have as much time to do these things.

One of these participants described his reflection of such fleeting thoughts as being fairly frequent:

Um, I suppose, to be honest, um, in just a very fleeting way you might think of this almost every day, uh, you know certainly several times a week. I'm at the stage now, where the first thing I turn to in the paper will be the obituaries (little laugh), because, to be conversant, I want to know what has happened to people that I know. And uh, I'm sure that's a sign of age, of the stage you're at.

The participants described various situations in which these fleeting thoughts occurred. The commonality for these situations was that such fleeting thoughts occurred during moments of solitary reflection when the participants were not actively engaged in interchange at the time the thoughts surfaced, as illustrated by one participant:

Now, all sorts of things will impinge, the telephone will ring or there'll be ... you know, so that you uh.. In the 20th century, or the end of the 20th century, I think we often don't have much time alone by ourselves, or we don't allow ourselves to be alone, which is a shame.

Two participants described a type of reflection that was longer and that was related to experience in relationships, as follows:

Well, I think very often um, one can say, I just want to get on sort of with what I'm doing now and you just push it out of your mind. And whereas, and, you know, you don't want to be morose about it, um. So, but, there are other times when you do think about it more fully if you go to a funeral of a good friend, or something like that. Or that period, where there is someone in your close circle of family or friends, who is ill, well then this will surface more.

Another participant related longer reflection which was triggered by his experience of autumn:

There are times that I'm driving along. You drive along through the fall and I suppose metaphorically you realize that you're sort of in that stage of life and everything is changing, and then the leaves eventually drop off and then so will you.

Three participants described brief or fleeting mental projections of anticipation of their own death into their conversations with their children (see Section 3 (ii)). However, most of the projecting described herein reflected integrative thought of long duration, as evidenced by participants referring to how they used to think, or how their thoughts had changed over the years.

In this introductory section, both fleeting and continuing prolonged reflecting and projecting, which the participants related, was described. For five of the eight participants, the relating of their experience of anticipating death of self included either fleeting reflections on their own future death or fleeting projections of their own future death into their spheres of being. Two of the participants initially stated that they did not ever think about their own death, and then went on to describe their fleeting thoughts. This commonly identified fleeting nature of reflections and conversations about death of self was an unexpected and interesting phenomenon.

Additional Supportive Quotes: Re:. The Nature of Reflecting and Projecting

1. Well, since I'm healthy I don't even think about it now. I honestly don't. Oh, maybe it might flash through my mind that I'm not going to be here forever.

2. Researcher: How often do you think about your own future death, how often does that enter your mind?

Participant: Well, very often lately, because of circumstances.[Her sister had died two months previously]. As I stood there in front of that packed church, giving that eulogy, I knew that most of them knew our family background. Uh, our mother had such a high cholesterol, she was used as a guinea pig years ago at Sunnybrook hospital and was glad to do it because she lived for about nine years after her first heart attack, so that, uh, and my father had died of that, and my sister apparently was loaded with cholesterol and I felt that uh, that people were looking at me standing there, and that I might self-destruct right there, and I began to, I was worried that with a family history like that I know that's very, you know, your family that you come from and their medical problems are a good part of it, so I uh, I came home and her doctor who was the head of cardiology at TGH, the Toronto Hospital then, uh, was concerned about me and she put me in touch with a doctor here who trained there at Toronto Hospital, and I went for tests. I was concerned, I thought, you know, another couple of years and I'm gone.

3. You know, that you've hit 65; this is the age where most people retire, and so therefore this is the right time for you to say, OK, let's bring this to an end, and then you look at the other things that you do, and you think yeah, OK, I can go from here, and this has ended, but I've still got this, but I'm going to end that sometime in 1996 and then I'm going to be left with this other option. So that in the process, I think of doing that and figuring that all out I think, you know that you suddenly realize that this is, you're on the downward slope towards your own death...

2. The Spheres of Being

The five spheres of being, as reflected in their description of the participants' experiences of anticipation of death of self, portrayed mental contexts of their internal selves and the projections of their internal selves to the surrounding world. The dimension of time, the simultaneity of reflection on more than one time, and, the simultaneity of projection to more than one sphere were apparent in participants' descriptions of their experiences.

The sphere of "internal being" concerns the reflection of the participants on themselves as beings without regard to anything external to them. The context of the physical world as it impacts upon the individual participant encompasses the sphere of "existence in the physical world as a solitary being". The sphere of "relationships with known individuals" concerns the relationships and interactions the individual has with family, friends, and other acquaintances. The place of the individuals in their immediate society and in the world society of humanity is portrayed in the sphere of "existence in the world as a part of humankind". The sphere of "existence after death" concerns the context within which the individuals believe they will exist after the death of their physical selves.

The experience of active reflection and integration by the participants provided the foundation for the sphere of internal being. In their sphere of internal being, the participants reflected on the internal experience of their feelings, values, and beliefs and the experiences in the other spheres. Participants were integrating the implications of their reflections by identifying, planning and effecting actions in the spheres of their existence in the world as solitary beings, their relationships with other individuals and their relationship to society as a whole, which were in congruence with their reflections.

3. Creating Readiness

Participants actively created readiness to die as part of the process of their experience of anticipating death of self. This theme constitutes a major portion of that experience, as evidenced by the elaboration of the participants of many subthemes. Participants discussed both facilitators and hindrances to creating readiness. The data are presented according to the model of the spheres of being, as described in the last section.

3.(a) Creating Readiness in the Internal Sphere

The theme of creating readiness in the participants' sphere of internal life portrayed reflections on accepting of the inevitability of death, identifying satisfaction with life, preparing for death, acknowledging concerns about the dying process and about the after-death experience, and projecting responses to those concerns. Readiness was a state in which both positive (ready) and negative (not ready) reflections occurred.

3.(a)(i) Accepting the Inevitability of Death

Death is seen as an inevitable part of life:

I think death, I mean, it's a reality that death is going to occur, I mean, that's one thing that you can't alter...I suppose in a sense it's a fatalistic sense of the reality that is going to occur.

Of the eight participants in this research, five had had the experience of witnessing the death and dying of others through either work or volunteerism. This experience may have facilitated their acceptance of death and their ability to reflect on death and to discuss it frankly. However, this ability was not limited to those with experience with death and dying. One of the participants who had never done such work outside her own family, stressed how important it was to be forthright about death:

There is a finality. What is it? - "There's nothing finite except death and taxes". So I think I've often thought, not really often thought about it, but I think you have to be practical. And I think people that shove it under the carpet, are just; they obviously can't face it...I think how I approach, again this is just the kind of person that you are; if I have a problem, I try to meet it head on.

Having had extensive experience in care of the dying through work, another participant was asked to elaborate on her statement that "life prepares you for the end". This participant used her family context to explain how she reflected on the deaths of family members and integrated those reflections into acceptance of her own eventual death:

Life experiences along the way, experiences of death of your family, your parents, your grandparents, you see that all come to pass and know that that will be my destiny. And in a sense, that prepares you in some way - a mind check - it reminds you that that will happen and it's OK, it's OK.

Additional Supportive Quotes Re: Accepting the Inevitability of Death

1. I really haven't thought about it in depth, it's been taken as part of reality, part of life, so to speak. It's uh, it has definite impact on people who are living as far as the separation aspect.

2. Well, let me put it this way, uh, dying is part of living. Everybody that's living, walking around or whatever, they're going to die.

3. Researcher: In general terms, what do life and death mean to you?

Participant: Well, life is, I guess I believe quite strongly in what we used to call the cours de flambeau, um, one generation sort of handing the torch on to the next generation, and you hand it on to the next.

4. I used to think there's: you're born; you're married; and, then you die! (laugh). You know, I've experienced the first two, but I've never experienced the last one.

5. Researcher: What do life and death mean to you?

Participant: Alpha and omega? The beginning and the end? Death is so final.

3.(a)(ii) Identifying Satisfaction with Life

Although all of the participants spoke in approving terms about themselves and their lives, six spoke specifically about their satisfaction with their life. Identifying satisfaction took the form of describing pleasure at having lived:

It's been a gift for me to have life.

Good health through a long life was related with gratification:

...and I'm in my 70th year, I've had 70 years, and they've all been good, I haven't had a broken bone or a black eye, you know. I've had pretty good health, that uh, you know, I should be satisfied. And I think that, I think that helps me a bit. And I'm not a complainer.

The pleasure of living was also characterized by a reluctance for life to end:

I think that uh, somebody who, you know, enjoys reasonably good health, and I don't think that I'm any different than other people in that, I don't know that I'm not; I think that if you enjoy reasonably good health, and you're still fairly active, and you're doing things you want to do, then um, that there's always, when you reflect on death, there's always a tinge of sadness, or you know, the fact that, hey, this is all going to end at some point in time.

One participant voiced the strong positive emotion that she felt with her satisfaction:

Content with my lot. And that's what we're supposed to be. I've almost got that peace that passeth all understanding, you know? You see? "Grant you the peace that passeth all understanding". I mean, I get little glimpses of that once in a while. Because you are at peace with the way you are. And it's important to have that. It's a good search for people.

Additional Quotes Re: Identifying Satisfaction with Life

1. So, uh, life to me is good; I've had sixty-six years of good health and success and happiness. I don't know how many more years I'm going to have, uh, I don't think about that too much, um, plan from day to day and year to year um, knowing full well that, perhaps at this stage of my life many people are diagnosed with illnesses, you know, chronic or terminal illnesses that, that uh, may shorten their life, but somehow, I don't really think about that very much, because I'm healthy. I, uh, actually I just had my annual physical yesterday, and he looks at my history and he says "You haven't had surgery or anything", and I said "No, I don't intend to" (laughing together) I don't intend to.

2. I feel fortunate, really fortunate, that I lived to retire, I just know all kinds of people that don't live to retire ... or just retire, and they're gone, you know? Um, and young people that don't even get to the, hardly even get into the workforce and they die for one cause or another.

3. But uh, well, I'm 69, I'm in my 70th year, you know. One time the bible said three score year and ten , you know? so I look at it, well I've, and my wife's the same way, you know she said we've lived our life, like, you know, she said this the other day, like every day we wake up, you know, it's really a plus, isn't it? If you really stop at three score year and ten, you know, we don't really stick to it,but it's some, something to think about, you know, uh.

4. Well, I can't think of anything outstanding in my life other than, I, I've enjoyed my life.

5. I have done a lot of things in my life that I never thought I would, and I've seen a lot of things I never thought I would. Um, I am pleased with my family, and I'm very proud of them.

6. I'm not saying I look forward to death, to be honest, um and I think it's possibly because life has been so good. If a person had a miserable life, I could see that they would be much more inclined to say they want that to end. Life has been very basically pleasant and rewarding and uh, you know one is reluctant to have that come to an end.

7. If you felt alright, everything that I could [have] wanted to do (or) has been done I think there is a certain regret you, because as I said before, life has been pleasant, and you are leaving something that is known, this is, I suppose the conservative in me (chuckle), known and pleasant, for the unknown, really. Um if, and I think there is also a certain amount of apprehension partly because of the unknown, I suppose. I'm not quite at the stage of Show Boat, "tired of living and scared of dying" (laugh).

8. I suppose it's almost a wistful thought, more than a hindrance ... the fact that, you know, you're not; that there isn't the completeness that you've envisaged as happening.

3.(a)(iii) Preparing for Death

Consciously preparing oneself for death was part of readiness for three participants. Readiness included reflection on the experiences and the feelings of changes in the body with aging:

I think as you grow older, your body gets older, you have a better understanding what life is all about, you've sort of integrated the happiness and the sorrows .... I think your body gets older and tireder, you know? I think that's part of the preparation. You don't feel the same, you have the vitality to live, but, uh, maybe it just isn't as important as when you're younger because you have a family to raise, you know, and you have responsibilities.

For another participant, preparation for death took the form of a life-long search in her religious life, which started in her teens, and continued in her adult years in membership in a Swedenborgian church:

I had to believe it [existence of life after death] because I was brought up to believe it, but when you reach the age of 15, 16, you start saying, well, say, where do I give? Do I just take it from what people tell me, the minister, my parents? I had to believe it for myself, there must have been something confirmed within me, not something someone says is right. I want to search it out myself. And so that's, I think, what is, fell in line the new Church [i.e. why I fell in line with the new Church]... You'd sit in church arguing with the minister; and, I mean in [her former] Church it was in my head I was arguing with him;...I used to think, there's: "You're born, you're married, and then you die!"(laugh). You know? I've experienced the first two, but I've never experienced the last one. Now how do I prepare for that?

One participant had an experience in which he found, much to his surprise, that he was prepared for death. Before he had major surgery, which he had been told entailed a risk of death, this participant was questioned by a chaplain:

It is probably an incident, a year ago that I had an operation, about a year ago. It doesn't seem that I was alarmed. Naturally I was surprised, when somebody came to see me; I think he was a, some sort of a clergy, a clergy. I did not know him, I think he just going around, and he started to probe with me: "Are you afraid, what are you thinking?" I didn't really have any apprehension as such, um, I even asked [his wife]: "Are you going to be here when the operation is here?" I said: "Well, something might happen". But when I said something might happen, it's an operation, major operation, and you never know what would happen, and I did not think that's its going to lead to death somehow. I just take it as; but when I said that, in my mind, the probability that something would happen, death would happen, was there. So, I was surprised, and I'm still surprised that I ... wasn't apprehensive about it.

Additional Supportive Quotes Re: Preparing for Death

1. Dying is part of living. Everybody that's living, walking around or whatever, they're going to die, you know, and I think it's kind of nice to prepare yourself to a degree.

2.Researcher: What sort of things do you think of or feel when you look ahead to your own death?

Participant: Um, could you be more specific on that?

Researcher: Um hmm. um, I guess if thoughts of your own death go through your mind, what are you picturing? Are you thinking in terms of I won't be here or what will be happening, or what sort of themes would there be when you think of death?

Participant: I'm not sure when I have, possibly I avoid something like this. I'm not sure when I have, um thought about it in very specific terms.

Researcher: So, its not something that you would spend a lot of time on?

Participant: Well, not at, perhaps one should, you know, because, let's face it, this is an, obviously it's an important stage of life and one should perhaps prepare for this the way one would for other important stages of life. The danger is that one lives life, as one's living it so fully,that you don't put aside time to do that. And perhaps, you know, if a person is ill, this is brought home to them more fully. Um.

Note: Although this participant stated here that he does not think of death, he went on to become one of the richest sources of data on the nature of the fleeting reflection of death.- Researcher.

3.(a)(iv) Acknowledging Concerns for Future Personal Condition

It seemed during these interviews as though the whole period of passage, from the perception of the first major deterioration to the event of death, was encompassed in the word 'death' for those experiencing the anticipation of death of self. Therefore, the participants included, in their discussion, elements of their future personal condition which one could speculate could exist for years before death, and which a younger person may not view as anticipation of death or part of the dying process. The two best examples of this were concern about widowhood and concern about a protracted illness.

Reflection on their future personal condition included the possibility of future widowhood for two of the participants. Having friends who were widowed triggered this thought for one participant:

The thing probably I fear probably the most is being alone sometime. That I think, uh, I have thought about that recently, never thought about it before in my life. But recently I've thought about: "oh my". You know, some of our friends, their spouses have died, and you know [I've thought]: "Wouldn't that be dreadful!"; "What would it be like?" Now I think that would be really difficult: to be alone.

Another participant identified and reflected on his inadequacies in sticking to a daily routine alone when his wife went on holiday for a week with their daughter:

I batched it. I said to my wife when she came home: "Well, you know, I learned something", I said. "I'd have to change considerably if you died". And I would, too. Like, for a week, I could manage, but I wouldn't want to live the rest of my life out the way I managed that week, because there was hardly no routine, you know, and I like my meals (chuckling). And when I had to make my own (laugh), that's a different story!.... As a rule, I eat on a regular basis. Well, when I was back here by myself, I could be eating my supper at 2 or 3 in the afternoon, if I worked and didn't come in, you know ... And I mentioned this to her, you know. I'd have to change, I'd really have to change. But, uh, and when things like this happen, say your wife goes away, or what have you, or if a man's wife, or a husband would go to the hospital for a while, it would give you a little bit of an inkling as what could be up the road, you know.

For seven of the participants, reflection on their future death included fear of the mode of their dying as part of their fear of their own future condition. This distinction was clearly made:

I don't think I fear death, I might fear dying more than death per se.

The mode of dying for these participants seemed to include all of the aspects of the passage from deterioration to death. In relating what she felt when she thought about death, one participant stated:

Uh, probably the end of your life, and what it means, and everything's over sort of thing, hm? You're, you're leaving your family, and the fear of pain and suffering, uh disabilities and uh losses, you know, uh?

Elaborating on her anticipation of disability, this participant showed great apprehension:

I can't, I couldn't imagine having a stroke and being paralyzed. That sort of thing, I need, I would be just stark raving mad likely, to think that I couldn't move or speak, if I was conscious enough to think in that way. But there are some very serious illnesses that can incapacitate you and can make you feel very, very useless, and it's all over, sort of.

The fear of pain and disability was echoed by others:

You're a little bit fearsome, and I think you fear perhaps pain, whether there'd be enough medical knowledge uh, if you had a lot of pain before death. Because some people just have a heart attack and die, other people have a long lingering death.

Encompassed in concerns for future personal condition was the reflection on a lack of control in death. This related to creating readiness for the unpredictable timing of the death event, and for the unknown degree of control of the circumstances of one's future dying. One participant related to the unpredictability of the timing of her death by: wondering how much time she had left; detailing the long lives older relatives had had; and projecting her planning for her future as being tentative, because her plans may potentially be interrupted by her illness or death.

I don't know how many more years I'm going to have, uh, I don't think about that too much, um, plan from day to day and year to year um, knowing full well that, perhaps at this stage of my life many people are diagnosed with illnesses, you know, chronic or terminal illnesses that, that uh, may shorten their life, but somehow, I don't really think about that very much, because I'm healthy.

Another participant also acknowledged the tentativeness of planning:

...whether you're allowed to carry through this whole plan that you're evolving, that, you know, there's one end here, another end here, another end here, [retirements from various aspects of the participant's work], and then there's going to be that final end somewhere; uh, that you really have no control over the question of the timing.

Lack of control was mentioned by two participants in the context of mode of dying:

The only say I have in the matter is that I can live a good life, you know, not go out and do anything that's going to bring a stroke on or anything like that. But, like I have no control of [that], like, that's out of my hands altogether. But I can be thankful that I'm not in that situation, and when it comes, whatever situation I get in, I'll have to accept. And down there [a chronic care facility where he volunteers], I can see a lot of people accepting.

Additional Supportive Quotes Re: Acknowledging Concerns for Future Personal Condition

1. Well, I wouldn't want to say that uh dying would bother me, maybe the way I would die.

2. If I had my druthers, I'd say, well, I'd like to go to bed and not wake up in the morning, you know.

3. There's a lot of stroke victims, an awful lot, your heart really goes out to them, because a lot of these people should be up walking around, some of them should be out working, some of them should be uh, raising families like, and here they're in a wheel chair and uh, like a stroke you don't very often get any better, you know, once you're in a wheel chair ... you know you don't come back 100%. So I really would not want to die with say a stroke, or something along those lines.

4. Well I suppose maybe you fear great pain, but we're so lucky, even I think Queen Victoria was one of the first people that had anaesthetic for the birth of her children. Uh, so that before that, even for a headache, you took some kind of mint tea or something or other, and, uh, so now we're so lucky we have pain killers, and you hope with the use of uh, drugs, even drugs that are forbidden on the street, uh, that pain would be reduced. I think pain is one of the things that people would fear about death.

5. I think, um one just doesn't know how one would relate to the pain, and whether one would be in control, I guess those are the things that I would have fear with.

6. I mean if I could pass on that easily, without great struggle. Now that's what bothers me is that when I go up to [the chronic care hospital] in the palliative care and also the other folks, what a struggle they're having. Always left in those rooms, moaning and groaning, some of them, and little ladies that have been busy, busy, busy all of their lives, just sitting there, wanting to do something. God, I thought I hope I'm not going to go through that. You know, that's what scares me. That part.

7. I don't want, let's face it, I don't want a very painful death and certainly cancer, and I think the ravaging of one's body, it must be terrible, and I'm not anxious, I'm not uh one who's interested in going through a lot of pain.

8. I see a heart attack as certainly, if one has a death of choice, it's probably the best.

9. I would hope that I would die of a heart attack, preferably, and not, certainly not, end up in a nursing home.

10. I think that you know, depending on what situation uh you find yourself in, uh, for instance when you look at people who are in tremendous pain, uh they very frequently you know, will say that they would like to die. Uh, and they're probably very genuine in that thought.

11. Well, I think, um one just doesn't know how one would relate to the pain, and whether one would be in control, I guess those are the things that I would have fear with.

3.(a)(v) Responding to Concerns

Four of the participants spoke specifically about the role that their religious faith played in supporting them when anticipating their own death:

I think life prepares you for the end. You know you sort of grow in knowledge and maturity and belief, faith. And the faith sustains you through those later years, it does for me uh, so you do whatever helps you, you know, whatever helps you most in life to get through you use those resources and uh, you succeed, as best you can.

Two of these participants who discussed the supporting role of their faith, in addition to one other participant who did not, discussed their unease. For these three, despite religious faith, apprehension or unease of what awaited them at and after death formed the experience of anticipation of death of self and reflection on this anticipation:

Researcher: What, uh, what helps you to face your own death? What kind of thing would you think would help you when you contemplate your death?

Participant: I'm not sure I can answer that question. Um, I really don't know. You know, I suppose and to some degree, you fall on your uh, fall back, uh if it's called a fall back, or you carry forward, your belief in God, or whatever. The divine force, whatever that you want to call it, however you want to call it that. Uh, and I suppose there are times that you envy those people who can sort of fairly wrap themselves into this and uh,

Researcher: Into religion?

Participant: Yeah, and sort of accept everything, you know, and go sort of marching on bravely into this uh without seemingly giving it a lot of thought, you know, that it's all laid out. And, and, you know, while I never, I always wonder whether you know, if one sort of stopped thinking and did this [accept literally the teachings of a religion which "lays out" exactly what occurs after death] that whether it wouldn't be a lot easier to uh, to sort of go forward in this fashion. Uh, I guess it's a, it's a question, it sounds like the question is the question, you know what actually does, you know, what does happen? I guess there's a, whether you want to call it a scientific curiosity or a curiosity of some sort as to, you know, what is the answer to all this, and of-course, it's the ultimate question and there isn't an ultimate answer that we've found. Uh, I guess the other thing is that there's a certain degree of acceptance, the fact that uh, you know that this is going to come sometime. Uh, I suppose you hope that it's not going to come until such time as you've as many of the, a lot of the things that you'd always wished you could do and wanted to do uh, and the relationships that you've wanted to enjoy. Uh, people that you've sort of been with. Uh, but, uh, you know really, it's really hard to sort of quantify it in that sense, uh, and I guess there are times when you know, you're just left in the wonderment of, you know, what really does happen, and you'd be less than honest to say that there wasn't a certain degree of unease there in the whole thing.

Researcher: Of unease ...

Participant: Well, you know, you, I don't know whether unease is the right word, but, uh, you know, the fact that there are these unanswered questions, and you really wonder about uh, you know what is the ultimate answer? What is going to happen? and how will things unfold when you're not here? I guess it all goes back in a sense into the control thing, that you're not here to control what you leave behind.

Additional Supportive Quotes Re: Responding to Concerns

1. Researcher: What kind of thing would help you face thoughts of your own death? or does help you now?

Participant: Um, well, I think your religion ...

2. It's the end of life on this earth, and the end of the physical kind of existence, and there will be another life. I don't know, have any clue what it would be, or what shape it would take, but I have the faith that according to my faith it will be a life, um, probably better, uh. Sometimes I obviously have the doubt like anybody else, could this be the end of everything, that's it. But that's not, that's just part, I guess of the process of faith that absolute aspect is not there. Faith is something that you do not see, you only perceive. Uh, and we don't know the shape of it but I have a strong faith that there is another life.

3. Having had a daughter die, at a very early age, and my mother, I loved her dearly too, she was wonderful... and with my sister dying, I think about it and I think an afterlife, if things are the way I feel they should be, then I will see them again, and that to me would um, it would be hard to leave here, leave this life, but there are other things there that I see, and I firmly believe in afterlife, in a God.

4. Participant: You know, but I believe in God, and the time comes that I die, probably I'll be ready for it then, I'm not sure. You know, you know, I think when you're very ill, it must be a relief to die, just the pain and suffering and the uselessness of just being sick and with no future, you know, uh, it's the only alternative, really, at that stage in your life. We all will die, and we all know that, and some will live longer than others. Some live more successfully than others. And uh, yeah there is a fear of death.

Researcher: Mmm mmm?

Participant: not knowing

Researcher:.You personally fear death

Participant: Yeah, yeah, there is some fear, but I think somehow, I'll get some help with that when the time comes.

5. Participant:.... as I said before, life has been pleasant, and you are leaving something that is known, this is, I suppose the conservative in me (chuckle), known and pleasant, for the unknown, really. Um if, and I think there is also a certain amount of apprehension partly because of the unknown, I suppose. I'm not quite at the stage of Show Boat, "tired of living and scared of dying" (laugh).

Researcher:.No. Too much living left.

Participant: Yes, right. That's right.But there's a certain, you know, there's a certain chord in that that people generally listen to. Obviously, that's what makes classics, things that appeal to a wide range of ...

Researcher: That they can identify that there may come a time when they feel that way...

Participant: That's right. Yes.

Return to Table of Contents

3.(b) Creating Readiness in the Sphere of Existence in the Physical World as a Solitary Being

Two participants discussed their readiness for death of self in terms of their existence in the physical world as a solitary being. One expressed how this was differentiated from other aspects of his life:

...in a sense in that uh, you tend to appreciate the things that you can see, that you can hear, that you can touch, and feel. In a sense I guess it's sort of the pleasure you derive from utilizing your five senses, and sort of your ability to think and remember and read and put it all in some sort of a context that uh, that you kind of kick around periodically...and that's sort of separate from relationships with people.

There was a sense of regret in anticipating leaving physical beauty and the enjoyment of the physical world behind:

I think the world is such a wonderful, beautiful place, I'd be uh, sorry to miss the spring and the fall, um, but then you'd think oh well, it would be better after death, and so perhaps this is a foolish earthlike thing to think about.

Additional Supportive Quotes Re: Creating Readiness in the Sphere of Existence in the Physical World as a Solitary Being

1. Uh, I guess it's a sort of um the physical beauty that you're going to miss going into the unknown, you know the colours, the sky, and that sort of thing.

2. And um, I'm getting arthritis in my knees, I know, so obviously I'm going to be hobbling around in a few years and maybe have to have a knee replacement or something or other, but I hope I'm never going to be without a sense of wonder. I think that's what will carry us through, and um, a sense of appreciation of things that are beautiful.

3. Uh, I think there's a certain finality with death as it's translated to us at the moment and I guess life is sort of a constant searching experience to uh to try and learn more about yourself, the world and the people around you and to enjoy the sights, the sounds the smells, the physical things that uh, are going on around you, you know. I guess natural beauty if you want would be a way of listing it out. Um, I suppose in a sense it might be a hedonistic approach, but uh there's just so much beauty in so many things that you can, well not only look for but you try to notice and enjoy.

4. Researcher: How often do you think about your own death?

Participant: I guess that's a difficult, uh, I'm not sure I can actually quantify it. Uh, I don't think it's something that I'm particularly obsessed about, uh, in other words, it's not sort of foremost in my thoughts, but there are times when for example I'm, and this seems to occur mostly in the fall I've noticed, or in the spring, uh, when you're kind of driving around or when you've heard that a friend has died, or someone you know has died, or something of that nature, you know I think the thoughts sort of surface and you wonder about them. Uh, but I'd have to say that probably the majority of times, maybe that's not fair, but certainly with as much frequency as anywhere else, is when I happen to be driving around and I'm, you know looking a sunset or the changing colours of trees and something like that and it sort of strikes you that when you die, are you going to miss seeing this sort of thing?

3.(c) Creating Readiness in the Sphere of Relationships with Other Individuals

Relationships with family in particular, and with friends as well, were a major focus in creating readiness for all the participants, as they reflected on anticipation of death of self. The theme of creating readiness in the anticipation of death of self in the sphere of relationships with other individuals included: the perceiving of impact on relationships; communicating in relationships; and anticipating comforts from relationships at the point of dying.

3.(c)(i) Perceiving the Impact on Relationships

The greatest difficulty for the participants in creating readiness for death of self seemed to be leaving the relationships they enjoy with friends and family. One participant related a feeling that he would be abandoning those he was close to:

You have some concerns or questions about your family and friends, and the fact that you won't see exactly how they develop beyond the states that they have developed to that point, and uh, what's going to happen in their lives.

In terms of their relationships with friends, there was an impression of a complete and total break in the relationship upon death. Three of the participants spoke about their friends in the context of saying good-bye:

I think that uh, friends that have been diagnosed with cancer, or other life-threatening [diseases], you think oh, there but for the grace of God go I, you know sort of thing. And it, it confronts you with the reality of your age and aging and death, yes it does. And at this stage in life, you say goodbye more than you say hello, to people, you know. It seems as if you're always, not always, but you're frequently saying goodbye, and it's so final. Its not like you're going off to work and saying goodbye, it's sort of a final adieu, you know.

Although all of the participants spoke with the importance of their families in the context of what they were saying, four specifically mentioned the predominant role which family played in their lives. For example, one said:

I guess what the most important thing to me would be my family. My children, my husband. My children's husbands and family, uh, we have seven grandchildren now. We started out with four, uh, actually five daughters and one died of leukemia, at the age of six. Uh, these girls have all married, quite happily, so far, and we now have five grandsons, which is just wonderful.

Rather than looking at the finality of the ending of the relationship with the family, as seemed to be the case with relationships with friends, participants spoke of the family as continuing. However, there was a desire to see the family doing well, with the intimation that one would be more ready for death if this were so:

Researcher: What kind of thing would help you face thoughts of your own death? or does help you now?

Participant: Um, well, I think your religion, your um family, the more I suppose you might see your family settled and happy ....

Additionally, there was a desire voiced by two of the participants to just be alive to see how the family turned out:

If I am with it, and healthy and still of some help, I would be happy to live into my 80s. I, that would be wonderful, if I could still contribute, could see my grandchildren, it would be wonderful to see them. I find children uh, are such fun, and they get to be more interesting as they grow older and I, [it's] particularly interesting to see these little boys. These five little boys, and what they do with their lives.

One participant took comfort in the way her sister's grandchildren accepted their grandmother's death, implying that she hoped that this may mean her own grandchildren would not suffer unduly when she died:

And I realize now that I don't feel, you know, I tell myself, I don't feel old inside. But I know that other people look on me as this. And I knew that when I spoke [giving the eulogy at her sister's funeral], and when the minister spoke to the grandchildren, my sister's grandchildren, that they were going to take this in a very different way, than I of course... But for her grandchildren, I realized this is, was, upsetting; but they would get over it ... But when an older [person] dies ... I see it as something that would be accepted by my grandchildren. I know they would be upset. But if I, at 20, thought my doctor, at 30, was old, I'm sure, I'm sure they have me down with the antiques (laugh)!

When asked what could hinder them in facing their own death, two of the participants talked about the difficulties that would be caused if there were unresolved issues in a relationship:

Participant: Well, I believe that [if] there's some unfinished business that people have with relationships, that need to be healed before death, I think it makes death perhaps more difficult, in that you might have more pain, I think [it] accentuates pain and causes more pain and heartache

Researcher: If you have that unfinished business?

Participant: Yes. Mmm mmm. If you feel some estrangement somewhere in a relationship, I think, I think that could be difficult.

One example of such unfinished business, which hinders the process of creating readiness, could be the lack of agreement with his children related by the second participant to mention this difficulty. His belief in the Christian "cours de flambeau" (tr. course of the torch) was frustrated by the lack of commitment of his children:

I feel that religion is very important, and at stressful periods in one's life, I found it helped. And our sons at the moment have not continued this, and this is um a sadness for us, but that's just the way it is...in this um, handing on of the torch, so to speak, this is an area that uh, well, to be honest, I have trouble with.

Another area of hindrance to creating readiness for death of self was mentioned by four of the participants who conveyed the possibility of having their death come at a time when they were badly needed by their family:

I would think that the one thing that would be difficult would be if somebody really needed me, I would find death difficult.

Caring for their family extended to a reluctance to be a burden on their family for three of the participants:

If I had my druthers, I'd say, well, I'd like to go to bed and not wake up in the morning, you know. It would be awfully hard on the family, but if I'm sitting or laying in [a chronic care hospital] for three months, six months, a year, two years, like a lot of people are, that would be awfully hard on my family too, wouldn't it? I would almost say that would be more hard on my family.

Additional Supportive Quotes Re: Perceiving the Impact on Relationships

1. Participant: I wouldn't want to put it out of my mind completely, but at the moment, I'm just so busy, I'm not thinking about death very often.

Researcher: That was going to be my next question. How often do you think about it?

Participant: I think it's in the back of one's mind, and when we go to funerals, and now we're going to a lot more funerals than we ever did before, you're certainly confronted with people that you know who are dying...

2. I think I've become more and more aware of it over the last couple of years I've had a number of classmates who were good friends die very suddenly and uh, it's always sort of a shaking experience when you look at that sort of a scenario. Uh, and it was interesting, we just had our 40th reunion this year, uh, you know to see the people who came back and the other interesting thing was to see the fact that a lot of people who perhaps we may not have been terribly close to 40 years ago, uh when we were going through school, although we basically were a fairly close class, uh, you know how much closer you were now when you found yourself in the situation and uh, discussing what was going on and you know the fact that at some point in time you were all not going, there wasn't going to be a reunion where anybody from this class was going to be present. Uh, so it was just interesting to see the various reactions and to feel your own reactions in those uh circumstances.

3. And I think when you're younger you don't think you're ever going to die, and I think probably as you get older, you begin to see your friends dying, and you think, my word!, man is mortal. And there is a finality.

4. I have a husband and a family: three children and six grandchildren who are a delight in my life, they give me a lot of happiness. They're a very lively bunch,and uh, they compliment Gramma on her cooking, and particularly on her pies (laugh), and uh, they love to eat too (laugh), and uh, they love to come here, and uh, that makes me feel good. And they have brought me, they have enriched my life too.

5. Well, I think that there are certain values that uh I perhaps, that I would try to relate to that give certain preminence. Uh, I always try to maintain a connection with um, I don't know whether [his wife] will have explained or not, but we're both convinced monarchists, but its a rather difficult time right now (laughing), its not the easiest. Um, and family. I think I'll leave it at that.

6. I have a very strong connection with my own family, with my children particularly, I don't have any other uh, significant outlying family.

7. I guess wondering how your grandchildren make out in life you know, they're usually fairly young when you die and you're just wondering how, how things go for them, you know?

8. Researcher: I wonder if you can think of a way that others, other people, could ever hinder you in facing your own death, what kind of thing, or if there is anything.

Participant: You mean like children needing you. Only if I'm needed, terribly needed for some reason.

Researcher: If you're terribly needed.

Participant: If I were terribly in demand, needed my presence, for some reason, but these are the only things that would

Researcher: Then there would be regret that

Participant: That I would have to leave before I did what I could for that person. You know, just thinking of a daughter, or a child or something that wasn't well, and a whole family of kids or something, needed you to be around.

9. Researcher:. I'm wondering, if you were facing your own death, in what way could others hinder you? What would bother you when you're thinking about that, or actually facing it?

Participant: Well, I suppose if certain family problems suddenly surfaced, or something like that. It probably wouldn't allow you to concentrate on that as much.

10. Researcher: In what way, um do others, or could others uh hinder you in facing your own death?

Participant: I guess to presuppose, uh to look at the question, if you're going to face your own death, then obviously you're copus mentis enough to realize that it's about to happen or that its somewhere in the uh in the not too distant future. I guess the greatest tug or hindrance might not be the word, but the greatest difficulty coping with the relationships that you have with your family and the people that you're very close to. Uh,

Researcher: In terms of, that would be the most difficult to handle if you were facing death?

Participant: Yeah, I would think so. I really can't think of any other significant hindrance that uh

11. I don't want to be chronically ill, uh, I don't want to burden anybody to care for me for long periods of time.

12. In response to a question of what would help him face his own death:

My family being there, but not to the extent, that uh, I would burn them out, that's something I really wouldn't want to see, is uh people, support people coming to me 'til it burned them out and had an effect on them.

13. I guess, for people dying of a heart attack, it's certainly the way to go. Having worked at the hospital and looked after people, or at least been there when people, have died of cancer, very, it's something that takes a long time, it takes so much out of the family. That I see a heart attack as certainly, if one has a death of choice, it's probably the best.

14. Well, I uh, I would hope that whatever way, at least, whenever I die, that it will be easy for my family, easier. Uh, I certainly, I'm terribly afraid of cancer, uh, certainly heart attack was, I know how hard it has been for me, but I think in the long run, perhaps it's easier. I have worked with people at the hospital and I see the caregiver often, and I'm sure you have, who maybe needed my attention more than the person in the bed. The person in the bed, has the nurses, has the support of other people, but the caregiver sometimes is destroyed.

3.(c)(ii) Communicating Within Relationships About Creating Readiness

Three of the participants related how they felt about conversing with their parents about death before their parents' deaths. One compared an intellectual discussion, such as the one he had had at his class reunion, with a family situation, and found the emotion of the topic inhibited the conversation:

Participant: My father lived only about 35 or 40 miles away, uh, and it was not something that we really talked about a great deal. I'm not, I think that was probably, well, it's always easy to say that it was probably a generational thing. But whether it was or it wasn't, or whether it was just the fact that it's probably not an easy topic for people to discuss, but uh, particularly in sort of a family setting. You know it's one thing to sort of carry on an intellectual discussion, but when

Researcher: Like you were at your reunion, you talked about [anticipation of death]?

Participant: Yeah, yeah. But when you sort of work in a degree of emotion to it and uh, a family relationship, then I think it becomes much more difficult.

Another of the participants related that, after the death of his parents, he had "felt at the time that there were things I wished I'd said." The third participant who discussed conversations with parents talked at length with her mother, who had in turn talked with her aunt:

Oh, I think I had conversations with my mother, uh, uh I don't think I did with my father, because he was wounded in the first world war and he would get emotional, and we thought, oh dear, poor Dad, we wouldn't want to put him through that. Uh, but uh, my mother had conversations about death with my great aunt, and I remember my mother saying that she thought it was like a butterfly, uh, that you were, you went through a period of change, and then, after death there would be a time that you couldn't fully comprehend, but it would be more like a butterfly emerging into another stage.

Conversing with their spouses about their own future death was mentioned by three other participants. One mentioned dealing with practical arrangements:

We don't dwell on it...we talk about uh, having all kinds of preparation as far as wills, as far as power of attorney, and so on, we talk about these things.

Another voiced frustration at not being able to talk with a spouse about anticipating death, saying that the spouse "avoids anything that is really, uh, cuts to the the heart of things". One of the participants, however, talked with his wife extensively about death and dying. He talked about being a volunteer with palliative patients:

Participant: All the patients I deal with are dying, you know, they're all terminal people. It gave me something to think about, and then, when I started to kind of study more or less bereavement and I seen how people dealt with it, and what they had to deal with, you know, how they handled, everybody's different, because they're all human beings, uh, gave me something to think about. And then I said to my wife, you know, these are things that we should really be talking about. So we do talk about it, about dying and what we would possibly do if my wife died and I was left with my daughter, or if uh, I die and my wife is left with my daughter, or if my daughter died. My wife and daughter get along fabulously, like it would be hard if, it's going to be hard enough on my daughter, when my wife dies, because they're so close. Uh, but I wonder what would happen if I died and my daughter died, so

Researcher: So you talk about all those things together, and

Participant: I would say there's not a week passes that we don't talk about it, but I'm not saying 5 years ago down the road uh, my wife would have discussed it maybe as easy as she does now.

With this openness, this couple was able to identify and solve differences about the way in which he had planned his funeral. He had been going to arrange for a full funeral, however after getting input from his wife, this participant arranged for his own cremation and a memorial service in his church:

She said I don't know whether I could hack a uh, be comfortable at a viewing, she said if I had to go to a funeral home for two or three nights, she said, I don't know whether I could hack it, and really and truthfully, I feel my wife's telling the truth. And I give her credit for that, because that's maybe a hard thing to admit.

Five of the participants mentioned speaking to their children about their own future death. Interestingly, three of these references revealed fleeting mentions, reminiscent of the fleeting thoughts of their own deaths described by the participants:

You sort of touch periodically with your kids about this sort of stuff, but not really to a great degree.

One participant talked about the fact that he had arranged for his son and daughter to make decisions about his wife and himself concerning removal of life support. When asked how they managed with that type of conversation, this participant indicated:

...they can handle it ... I don't think it's easily.

The same participant who talked to her mother easily about death, took care to accustom her children to death:

And I think it's hard for, extremely hard for anyone, but we have taken our ... two boys ... to funerals where we thought it was appropriate, from when they were fairly small, and we said, "don't worry about what you'll say to the people who are there". Uh, we explained, we spent a lot of time explaining that, "there'll probably be, um, a box, called a coffin, that this is where the body will be and sometimes the lid will be open, and sometimes it won't, but that uh, the important thing is just to give the people who are there a hug, and it doesn't really matter what you say, just your presence would be the most important".

Five of the participants expressed concern for the inability of some of their peers to deal with the topic of anticipating death of self:

People don't talk about their faith very much or the end of their life or their, uh, I, I find that generally, people try to avoid those topics, and uh, I don't have any problem thinking and doing that, but, I don't know many of my friends that would feel comfortable talking about it. Uh, they'd like to deny it, there's a lot of denial about that, and life and uh, sometimes, uh I have friends that probably aren't as comfortable with themselves and aging, as maybe I am. And I would hope that they could reach that zone of comfort somewhere along the way? But I'm not sure how to help them with that, you know its a very personal thing, and unless they reach out and want to talk about it, then you're not going to do anything about it, because it just, it seems, it would probably worry them, you know? And I wouldn't want to create that kind of anxiety.

One participant, when asked if there was anything else she'd like to tell about how it felt to look ahead to her own death, stated the concern that was implied by other participants:

I just wish I could share what I've got with people that are cringing at the thought.

Additional Supportive Quotes Re: Communicating Within Relationships About Creating Readiness

1. Participant: I felt now that I keep repeating to the children well, I won't be here long with you, but, again, so

Researcher: So you talk about it with the children

Participant: Well, when something happens, I just, when I would like to stress a point, or something, that you have to look after yourselves, and uh, so on, I just repeat it, I felt that I'm repeating it more now than before, just being cognisant of my age. But again, uh, without feeling that it is something that is sad, or, just stating it as part of reality, that everybody's going to go and uh I am old and closer to that part and ..

Researcher: What is their reaction, when you do that?

Participant: "Oh yes, OK Dad, OK" (laughing).

Researcher: So they're, they just flow with it.

Participant: Yeah, they don't dwell on it, and I don't make them either, I just like, this is what will be."

2. (After he had mentioned his regret at not having talked to his parents):

Researcher: Is this something that you have ever talked about with your own children, or [wife's name]?

Participant: Um, I'm not, no I don't think I have, I probably should. You know, but certainly not to sit down and, just fleeting references and things like that.

3. There are times when I try to face the reality, and I've sat down with my kids and uh, sort of expained, uh tried to lay out for them uh, you know, how things are set up, I suppose in the uh, in the sense what the survivors are going to enjoy or not enjoy, type of thing. And I don't think they're any different than anybody else, they don't find these conversations particularly ones that they want to enter into. But, you know, none the less, they listen.

4. When I talk about death, some people will say, well, don't talk about that!, you know, we don't want to talk about anything that morbid, you know; I think they're missing the boat, you know, but I, I quit talking if that's their way of feeling, I don't talk about death but like I think people should realize, death's going to come to them eventually. And I do have friends that wouldn't talk about death.

5. But you see I know some people who won't go to funerals, and uh, their excuse is, well, I'll just break down and cry. Well, I think that's just simply ridiculous. That's being, you know, playing child.

6. I think certain people think about this sort of thing more than others and uh, you see some would be so fearful and so afraid that they would push it out of their minds completely.

7. Participant: Uh, and it was interesting, we just had our 40th reunion this year, uh, you know to see the people who came back and the other interesting thing was to see the fact that a lot of people who perhaps we may not have been perhaps terribly close to 40 years ago, uh when we were going through school, although we basically were a fairly close class, uh, you know how much closer you were now when you found yourself in the situation and uh, discussing what was going on and you know the fact that at some point in time you were all not going, there wasn't going to be a reunion where anybody from this class was going to be present. Uh, so it was just interesting to see the various reactions and to feel your own reactions in those uh circumstances.

Researcher: Is that something that you talked with your classmates about at the time, or

Participant: Yeah, we did spend some time um sort of kicking it around and talking about it. Some I think probably were a little more open than others. I suppose all of us are, there seemed to be very few of us who uh, probably talk as frankly or fully about death as you might. Even though I suppose a great many of us depending on what we ended up doing have all you know, seen death and seen people die on many occasions, and been there when they did die.

3.(c)(iii) Anticipating Comforts from Relationships at the Point of Dying

Six of the participants discussed the type of things that they felt they would like done for them, or should be done generally for people who are dying, by those with whom they have close relationships. Four participants talked about the caring interaction they hoped would be available to them. One of these talked about his interaction with palliative patients and his hope for the conditions in his own anticipanted dying:

Really to me that's all counselling is, isn't it?, to be a good listener, you know, let the people let their emotions flow, and be sympathetic and caring, and I hope some day, if that's me laying in the bed, I hope there'll be somebody there for me. I really do. I really do.

Additionally, two participants talked about how important it was to let people know they were appreciated:

I think another thing too, and this should be done long before you die, this should be, like I do this with my wife, like. Tell them how much they're appreciated, you know?

Generally, the concern of these participants seemed to be that they had kind company at the point of dying:

Just give me your tender loving care, and I'll try to cope with the rest.

Additional Supportive Quotes Re: Anticipating Comforts from Relationships at the Point of Dying

1. Researcher: In what way could other people hinder you from facing your own death?

Participant: Hinder me. Well probably not dealing with it when the time comes, that they couldn't talk to me about it you know, uh you know, try to say, "oh, you'll be OK tomorrow", and you know right well you're not going to be? Sort of a, sort of a saluatory kind of comment that they're trying to make you feel better, but come on, (laugh) don't give me that crap! (laughter) Anyway, I don't know what else, uh, probably, probably avoid visiting, and talking, those sorts of things? The social network being uh closed down down you might say? The support and the care and concern of the community of friends I think that would probably bother me. Loneliness. Yeah, that probably would.

2. I would think possibly, even to discuss it with me would help.

3. But I think we need people to be with others who are dying and not fear it, and you know, even hold their hand!

4. Researcher: In what ways could others help you in facing your own death?

Participant: Just say they love me (laugh). You know, say, we're going to miss you, Mom.

Researcher: So that's sort of validation of yourself as a person. Your worth to them.

Participant: Yeah, yeah. And I get that quite often, as a matter of fact, I just got a letter the other day from my former daughter-in-law, they're not married anymore. But she wrote a letter saying how much she treasured my, you know, influence on her life and you know, what fun it had been when they lived around the corner with the kids growing up. And, you know, things like that make you feel good.

3.(d) Creating Readiness in the Sphere of Existence in the World as a Part of Humankind

In projecting and reflecting their thoughts on their future death into this sphere, participants drew inspiration and positive thoughts from humankind in creating their own readiness. Participants also expressed concern about the ability of others in humankind to create readiness.

Inspiration for creating readiness was gleaned by three participants from reflecting on how others in humankind dealt with death with great strength, rather than concentrating on the loss. One participant was creating readiness by being glad to know about people whose religious faith enabled them to celebrate the passage of a loved one into the next life:

Participant: There are a few incidents that I find quite remarkable. In some people I heard about, they lost somebody, they were Christian, and they really celebrated, they never grieved, but they really celebrated.

Researcher: Celebrated?

Participant: The death. Rather than being comforted by their faith. When I see some of these examples, it strengthens my faith, it enforces yes that faith has a place even under these conditions.

Gleaning inspiration and admiration from a casual conversation with someone nearing death, provided an example of creating readiness from humankind given by one participant:

Participant: Say, if some little old guy will say, "Well, I don't think I'm going to be here much longer". I said, "Well, if you're ready, you're ready, this is your preparation, right?" You know, he wasn't feeling morbid about it, he was just sort of half kidding.

Researcher: Yeah. What was his reaction?

Participant: Yeah, he agreed, yeah. He was ready to go. This life is a real bother for him, he's in a wheel chair, and he's got little plugs in his nose because he couldn't breathe, but he was doing all he could, and he'd play poker when some of his relatives would come in, they'd bring a dog in, and so, he was with it up to the last. And you admire these people that under all these terrible circumstances, can still be living up to the last. You know, and enjoy.

Creating readiness from the inspiration of some positive feelings by humankind about funerals was also described. One participant talked about how they had given her father a "really good send-off" and was still touched by the respect shown by strangers:

I remember in the motorcade to the funeral ... and you know you go through ... that farming community and the people in the field just stop, you know, and respect the motorcade? It was really amazing, you know the farmer would stop. I just noticed when or, it was June, they were out in the fields, and they would stop and respect, you know, that occasion.

One participant was projecting concern about the future of humankind, in relation to creating readiness for his own death:

Uh, you sort of question how the unfolding of the world is going to go. Sort of kick those ideas around and realize that you're not going to be able to, or potentially, you may not be able to participate in that.

This participant also expressed concern as to the influences on creating readiness for death generally amongst humankind:

Participant: I think on the one side there's, if you're young you reject the concept, uh, you know, you sort of have the feeling that immortality is just around the corner and uh,

Researcher: They'll find a cure ....

Participant: Yeah. So that you don't, it's not something that you really uh. Then you know, all of society is geared to that isn't it? I mean you can now be totally replumbed from top to bottom, and you read all of this stuff that you know, you can cut out coronary artery disease and you can do this, that and the other thing and of course the public's all for it. And then you stop to think, but you're missing the basic reality, that at some point, as far as we know, within the current level of knowledge, you're not going to be here. So, uh, whether you die of coronary artery disease, cancer, Alzheimer's disease, or you know, whatever, uh or bronchopneumonia, there comes an endpoint, there is an endpoint to this life. And so why are these people sort of, you know, uh, coming out with all these marvellous statistics, you know we can do this that and the other thing, all they're doing is taking their own little narrow slot and saying, "Well yes, you know we can sort of make you survive uh ten or fifteen years longer in this particular field". But they never say: "But something else may get you in the interim".

Two of the participants talked about their concern about the difficulty in creating readiness they had seen others in humankind having when they were dying. This lack of created readiness was described as an "unwillingness to let go":

I guess the other thing that is really sort of always bothered me, uh , in that I've always wondered about it and spent some time in thinking about it, is, I've dealt with a number of people uh, who have been terminally ill, and who I think uh, while they were well had sort of sought comfort from religion or whatever, uh, and then when they were sort of stuck in the situation where they were in terrible pain, uh, were quite literally afraid to die, and ended up surviving through what I could only describe as sort of a living hell with the pain that they were going through. And you know, they just were totally unwilling to let go, and it sort of made you think, do you as an individual have that sort of capability to hang on to what certainly was a bitter end? Uh, and uh, it's always been something that I sort of, not that I always think about, but every once in a while it sort of comes to mind as to seeing the way people approach their death and their acceptance of it or their non-acceptance of it. So, and uh, the agonies that some people put themselves through, primarily I think because of the non-acceptance of the fact or the fear of uh of not knowing what's going to happen, and just being terrified at letting go.

In a completely different focus, concern for humankind in a historical sense also affected the creation of readiness of a participant, in terms of wanting the answers to interesting historical puzzles; "lots of wonderful answers to the questions that we ask":

Somebody, I can't remember her name, it wasn't Lady Stairs, but Lady Somebody or Other who lived at the time of Mary, Queen of Scots, said I'm really looking forward to death, because then this problem of Darnley will be completely solved and we'll know who was responsible, whether it was Bothwell, or Mary herself, or how this business that Darnley was blown up.

Additional Supportive Quotes Re: Creating Readiness in the Sphere of Existence in the World as a Part of Humankind

1.Researcher: What form would the celebration have taken?

Participant: These things I think I read about, even some time I think I knew, but this was some time ago, I don't really recall. They didn't want people to cry, I think, or to do any of the, some of the rituals of desperate aspects of sadness and so on. They were able to support others..

Researcher: The people who were most affected were...

Participant: Yes, the father, in this case I think it was a father specifically. Yeah, they were the ones who were able to support the others who did not have as strong faith as, as they do. So these I think would be examples of ...

Researcher: So that kind of dealing with death amongst your friends, your family, that that's a positive thing for you in dealing with it yourself.

Participant: I think another close example that I think about was a lady in our church who was in her early 30's I believe, and she has cancer, and this was in the last two years, um, and that lady never complained much at all, until the last, I think, week of her death, she was in the church doing all kinds of things and very cheerful. It just amazed... I mean, she knew that she was going to die, and that example is a very vivid and um, its just something that I found very beautiful. That here is a lady quite young, and she knew she went through all kinds of medication process, and through all of that, she did not be an introvert, she went out, she sang in the choir, she did all kinds of things, she came to our meetings here and she laughs like everybody else and she doesn't want anybody to feel sympathy for her or anything, just amazing. But I knew that she has a very, very strong faith, so these are examples that ...

Researcher: So seeing her go, seeing how her faith held her through that ...

Participant: Oh yeah, it was very impressive, unquestionably.

2. I once read in Time magazine, of Grace Kelly's father just before he died, and he said, now I'm really quite looking forward to this, because it's an experience that I haven't had before, and don't worry about me, I'll be alright. I thought that was quite significant.

3. My cousin, passed on, the one with muscular dystrophy, she died, and we were pretty close. We used to have our little drinks of Scotch until she got gall bladder problems and then she couldn't have it any more, so, what a revolting development (laughter)! But anyhow, when we going in her funeral, in the procession, and we you were driving in the limousines and everything, it was, boy! [She] would have enjoyed this! (laughter). It was sort of, the queen going by, you know, I was thinking about her, where are you now, where are you right now? You're not observing this thing right now, but you'd get a big kick out of this. I mean, I wasn't so deadly serious about the whole thing, you know?

4. Well, like, what bothers me a little bit sometimes, well, just, I'll use [a chronic care hospital] as an example, when people are afraid to die, yeah. Uh, like I always watch when I'm down at [the chronic care hospital] and there's family there and support, and the patient is within hours of death, like, you know. If I'm by myself, you know, I'll say to them, you know, it's quite alright for you to let go, you've had a good life. And they claim they can hear, they claim that hearing is the last thing to go, you know. And maybe I get no response back, but I say, you know, you feel free to let go, feel free to let go. But I don't very often see their support, like the family, say that. There is some that do, and I think to myself, gee I wouldn't want to be in that boat. My wife is dying [i.e. if my wife was dying], and I knew there was no hope and it was getting near, I would be telling her, you know, to let go... I would appreciate it if [my family] said, you know, OK Dad, we've did well by you and if you feel like letting go, let go. 'Cause some people live, for maybe their children or uh, husband or wife or they hold on.

3.(e) Creating Readiness in the Sphere of Existence after Death

All of the participants in this study believed in their life continuing after death, and all were Christian. When asked to describe what death means to him, one participant responded:

It's the end of life on this earth, and the end of the physical kind of existence, and there will be another life, I don't know, have any clue what it would be, or what shape it would take, but I have the faith that according to my faith it will be a life, um, probably better, uh. Sometimes I obviously have the doubt like anybody else, could this be the end of everything, that's it. But that's not, that's just part, I guess of the process of faith that [the] absolute aspect is not there. Faith is something that you do not see, you only perceive. Uh, and we don't know the shape of it but I have a strong faith that there is another life.

In discussing his father's death when he was a teenager, this participant outlined the significance of Christianity in his beliefs:

I could not understand death, [the] meaning of death at that time. Again, my friends at that time, as Christians, and we believe that the person did not really die, he just went to another level of life and um, so that's the comfort which we as a Christian would usually get.

One of the participants had spoken to many people who had described out of body experiences, and to many others who had near death experiences, in which:

"they see a bright light and that they're drawn towards it like a moth to the flame".

This participant concluded that God, or some sort of guiding force or spirit, and life after death, must exist.

One of the participants talked with certainty about what life after death would be like:

When we die, our body is dust to dust, uh, I firmly believe that the spirit will be resurrected and I think you'll meet all sorts of people who have gone before.

Five others talked about their uncertainty about what life after death would be like:

Spiritual life is really hard to explain, you know, and uh, you have a sense of what it is, and you understand it, but uh, there'll be surprises along the way, I'm sure.

For one of these participants, wondering about the form of life after death was a subject of intense speculation:

Then you go into the sort of thing that - Are you just part of the great ether floating around on the outside as an energy source? and - Do you believe in reincarnation? and - Will you sort of be the monarch butterfly, or whatever, that kind of floats around? Uh, there's [not] really, I don't think, any specific uh concentrated thought that goes into it....And I guess when you do go to church you hear about death and the resurrection and you try to sort of translate this into uh what does this really mean? And I guess if you accept it literally, you know you have the feeling that the sky is filled with all these people who are shadows of their former selves and that there's these eons of multimillions of people that are up there uh, floating around. And yet that really, when you look at it in a pragmatic sense doesn't seem to be a reasonable reality in that sense. I guess it's a question of uh, always trying to come to grips with what is unknown, uh in essence, other than the physical act of death which uh which, you know, you've seen.

Additional Supportive Quotes Re: Creating Readiness in the Sphere of Existence after Death

1. Well, you know the body, the spirit goes to heaven and the spirit lives there til the end of time, and God is there to take care of that spirit, see?

2. I think my belief helps me, to a degree, I do believe there's a better place after we leave here, I firmly believe that. I don't wish it on anybody, I don't try to convince anybody, you know, that's my belief.

3. Well, I believe in the resurrection of the dead, and so I think it's another aspect of our life.

4. Well, no, in an orthodox way you talk about the resurrection of the body, I'm not sure in what shape or form this is, you know, would take place.

5. Researcher: So when you think of your own death, do you think about a sort of the event, or do you think in a negative sort of way, I hope it's not long and drawn out. That's mainly how it is, or?

Participant: No, I don't. I think about beyond, I just hope it isn't going to be. I just wonder what my use is going to be in the other world. I used to think, you know, I'd like to be in the blood, you know, circulating here and there and going all over the grand man in heaven. And I like to travel.

Researcher:. So it's almost an anticipation for what's coming.

Participant: Yeah. Well, I mean this is just our preparation, is what we feel. It's our proving ground here, so you realize, for the real life, where our place is going to be eventually, on the way we've lived our life.

I firmly believe in afterlife, in a God.

6. Then you go into the sort of thing that are you just part of the great ether floating around on the outside as an energy source, and do you believe in reincarnation and will you sort of be the monarch butterfly, or whatever that kind of floats around. Uh, there's really I don't think any specific uh concentrated thought that goes into it.

7. Researcher: So when you think of your own death, do you think about a sort of the event, or do you think in a negative sort of way, I hope it's not long and drawn out. That's mainly how it is, or?

Participant: No, I don't. I think about beyond, I just hope it isn't going to be. I just wonder what my use is going to be in the other world. I used to think, you know, I'd like to be in the blood, you know, circulating here and there and going all over the grand man in heaven. And I like to travel.

Researcher: So it's almost an anticipation for what's coming.

Participant: Yeah. Well, I mean this is just our preparation, is what we feel. It's our proving ground here, so you realize, for the real life, where our place is going to be eventually, on the way we've lived our life.

8. I would hope that there would be perhaps, there would be a reunion with people that you were fond of, but again, some of these things aren't absolutely spelled out, so you don't know.

9. Well, I suppose it's crazy to think and to talk about it, but having had a daughter die, at a very early age, and my mother, I loved her dearly too, she was wonderful. Uh, she had a tough time bringing us up because did it pretty much on her own. She brought up four of us on her own. Her marriage was broken, and with my sister dying, I think about it and I think an afterlife if things are the way I feel they should be, then I will see them again, and that to me would um, it would be hard to leave here, leave this life, but there are other things there that I see.

Return to Table of Contents

4. Achieving Purpose

In relation to the anticipation of death, the participants described actively achieving purpose in such a way that it appeared to pervade most aspects of their lives. The data are presented here according to the model of the spheres of being, in order to clarify the meaning of this theme for these participants. In many instances, the quotations reflect the fact that achieving purpose has been a theme in the participants' lives for their entire adulthood. Anticipation of death seems to entail integrating one's notion of what can be accomplished before death and the possibility of no longer being able to achieve purpose.

4.(a) Achieving Purpose in the Internal Sphere

When discussing anticipation of death of self, all eight of the participants reflected a strong need to accomplish in their lives. Seven of the participants talked about this need in general terms:

It seems to me I've always, uh, felt the need to accomplish tasks in my life, and, uh, feel good about what I'm doing, and even go beyond that and help others as much as I can to reach their potential, at the same time work on my own, I guess you would say self-actualization... And I still want, I have goals that I want to achieve? And I keep looking ahead to see what else I can do in life? for people? And I've benefitted a lot from this myself, I believe it has helped me be successful.

Needing to get one's life work accomplished was part of this need for some of the participants. When asked what could hinder him in facing his own death, one participant replied:

I guess if you thought that things that you want to accomplish are not accomplished in your lifetime. Uh, really, if things were not tidied up, and desires that were not fulfilled, whatever, would affect...[sentence trailed off here].

A similar sentiment was voiced by a participant who related thoughts that she had had while doing genealogy:

Participant: Then you think, oh my goodness, from stories, I thought she was fairly old when she died. My goodness, I'm older than she is now. And then you think, my goodness, they were only 40 when they died. Uh, I wonder if they accomplished all the things that they wanted to do in their life? Perhaps not if it was a sudden death.

Researcher: So you're reflecting on, are you reflecting on your accomplishments and how you ...

Participant: Yes, I think horrors, I haven't done half the things I want to do. I'd better get busy.

Another participant spoke of her entire life work being in anticipation of her death and her life after death:

Participant: Well, I mean this is just our preparation, is what we feel. It's our proving ground here, so you realize for the real life, where our place is going to be eventually, on the way we've lived our life.

Researcher: The term proving ground intrigues me. I wonder if you could talk about that just a little bit in terms of uh, what form the proving takes?

Participant: Well, charity is important, isn't it? Being charitable, in all aspects of your life. And I always think, in as much as you've done it for the least of these, you've done it for me. That's the only way we can really serve the Lord, isn't it? By doing this on earth, because he's, through us, doing it. All the things that people do for other people. It's like the good Samaritan? It isn't really very complicated, is it, when you get right down to it.

Speculation that there could be a sense of satisfaction when actually facing death was voiced by one participant:

" _...there could be a certain sense of satisfaction ... if you felt alright, [if] everything that I could [have] wanted to do [is], or has been, done."_

Two participants seemed to be evaluating what they were doing from day to day in terms of how long they had left to live. One had just finished a month of putting on a local production of a musical:

Participant: It's almost, that is, I don't know whether its fair to call it a love-hate relationship, uh, I, there are times that I'm very fond of it, and there are times that I, you know, that I groan, because it means putting aside something else that I want to do. You know, something like we've done the last month, it was just a month out of my life.

Researcher: You've very little time for anything else.

Participant: That's right, and at a stage where, you know, I don't have years and years and years ahead of me.

Another participant, who stated that an important purpose in life was "doing for others", had her mother's guideline as a personal yardstick: "My mother always said you don't leave this life without having made it, if possible, a little better." However, she seemed to have reached the sense of satisfaction that a previous participant speculated on as possible, although she indicated a wish to go on doing things:

I will do everything I can that's reasonable to extend my life ... I'm having a lot of fun. I love to travel, and there are lots of things I still want to do.

The participant also indicated a contentment with the things she had done:

There are a lot I wanted to do, but I have done some of them; I've done a lot of those things that I thought [I wouldn't], and I won't feel I have missed it.

Another participant viewed doing things as important in order to keep living:

Participant: There are times when you plot the ending and you really don't think that much about it, but I think that when you sit down and kind of reflect on what's happening and what's going on, you know you realize that this is an end to this phase of your life, and so you're going on to the next phase. But you're at the stage now, where, it's not to say that there aren't opportunities opening up for you to do different things, there are. Uh, and you have to sort of gear yourself to be willing to accept those challenges, rather than just accept the fact that, you know, this is all ending, this is ending, this is going to end and it's all going to go downhill.

Researcher: So you just carry on and ...

Participant: Well, yeah, and I get, I don't know whether that's a natural response, uh, I guess if you watch people for a long period of time, the ones who survive; and maybe that's what we're all in this for is survival; uh, are the ones who seem to have something to look forward to or some reason to carry on. And uh, you see those people who don't appear to have a reason or who give up, in, I suppose in a sense, uh, they die very quickly.

A sense of purpose in this internal sphere of being, for many of the participants, included a need to keep well:

I, uh, actually I just had my annual physical yesterday, and he looks at my history and he says "You haven't had surgery or anything", and I said "No, I don't intend to, I don't intend to". But I really concentrate on living a healthy life.

The process of achieving purpose included the experience of reflecting on threats to achieving purpose in the internal sphere. One of the threats was the prospect of being dependent for care at some point in the future. For half of the participants, staying well included staying independent, able to accomplish things, and not having to have others take care of them:

I don't want to be chronically ill, uh, I don't want to burden anybody to care for me for long periods of time. I want to stay as healthy as I can and be as independent as I can.... But there are some very serious illnesses that can incapacitate you and can make you feel very, very useless, and it's all over sort of. You can't do anything anymore. You can't be independent anymore, you've got to depend on [others]. And I guess that's one of the things I fear most is being dependent, I want to be independent, do what I can to take care of myself. And it's probably, with our health care system, that's the way it's going to be I think (laughing).

Another example of experiencing threat to achieving purpose was illustrated when one participant voiced the experience of having both a need to do things and an uncertainty of being able to actually carry out plans that he'd made:

I'm not sure that I have profound thoughts about it, and I'm not even sure, that, you know, to glibly say that I have acceptance of the reality, uh, that it is going to happen at some point, really is terribly helpful. Uh, it uh, you know I know that it, I know that it is, at one level. I guess at another level you function as though it's not going to happen for a few years yet, because you know there are a few things that I would really like to do, and places I'd like to go and see. Uh, and yet I think the reality is that I have no control over that.

It was important for the participants to anticipate that they would always be enabled to enact their own sense of purpose. However, from the participants' description, both active process themes appeared to dynamically vary in different aspects of the participants' mental context. As mentioned earlier, in the process of creating readiness, the participants were both ready and not ready in various realms at the time of the interview. Similarly, the process of achieving purpose also had different states. "Reflecting on formerly achieved purposes"; "planning to achieve purposes"; and, "reflecting on the possibility of being unable to achieve purposes by projecting the potential development of threats", were three states of the process of achieving purpose in the internal sphere.

Additional Supportive Quotes Re: Achieving Purpose in the Internal Sphere

1. Well, like I've been retired, it will be 5 years in February, and when I had a dairy business, and I sold it, and I came home that day, it was on a Tuesday, I said to myself in the car coming up from Cambridge, this is the first day of the rest of my life and I have to make good.

2. I always kept that in my mind, that as long as I live, I tried to look after my mother, even though I wasn't the oldest one, and I still felt the responsibility towards that.

3. Well, I suppose I believe in the Protestant work ethic and I think that we have a duty to the space in which we have been placed. Um, I think probably we're extremely priviledged when you think of people in Bangladesh and uh, Sarajevo, so that therefore we owe it to society to pay back a little bit of what society has given us.

4. I think how I approach, again this is just the kind of person that you are, if I have a problem, I try to meet it head on ... and I keep trying to reorganizing priorities of what I have to do, so that I'm probably hard on myself. But I wouldn't feel comfortable if I didn't get some of the jobs that I set myself, some of the tasks um done.

5. I guess the other thing is that there's a certain degree of acceptance, the fact that uh, you know that this is going to come sometime. Uh, I suppose you hope that it's not going to come until such time as you've as many of the, a lot of the things that you'd always wished you could do and wanted to do uh, and the relationships that you've wanted to enjoy. Uh, people that you've sort of been with. Uh, but, uh, you know really, it's really hard to sort of quantify it in that sense, uh, and I guess there are times when you know, you're just left in the wonderment of you know what really does happen, and you'd be less than honest to say that there wasn't a certain degree of unease there in the whole thing.

6. I suppose in a sense it's a fatalistic sense of the reality that is going to occur, and so you need to do as much as you feel you want to do to experience what's going on here.

7. I guess maybe that's you know, how you've seen older people sort of resigned to the end, and I think they felt they've done their work, they've uh, prepared themselves, uh, to a point.

8. I guess there's always, the thing in the back of your mind, that uh, you know, there are certain things that you still would like to do. Uh, you know, are you going to have time to do it, uh, and, you know, when somebody you know dies or whatever, under whatever set of circumstances, there's always this always this question, you know, well should I should I really sort of hang on to what I'm doing now, and you think, well, next year we'll do this that and the other thing, then you get the thought, well, you know, next year, that's not a long way away, and who knows what can happen between now and next year. Maybe we should sort of re-evaluate this sort of whole thing and think maybe we should go now and forget the next year. So you kind of kick those things around a little bit, and I suppose its the same, it leads to the same final end point, that uh, you know you're not going to be here in perpetuity to sort of do all these things that you think you'd like to do, that there are only a certain number of things that you're going to experience, and then it's game over.

9. The only say I have in the matter is that I can live a good life, you know, not go out and do anything that's going to bring a stroke on or anything like that.

10. You have to go on and do the best you can and live as long as you can, because I really believe that uh, if you do as much as you can to stay healthy, if you can live to be a good age and enjoy life, and you can um, I think there are a lot of things, you know, when you think of all the chemicals, and the smoking problems and all of that along with the, sometimes you wonder how you really managed to get here! you know, so healthy! And you feel very thankful for it mind you.

11. I go to the Y and run. I've been trying to run three times a week and I've done it for years, I've been a Y member for years, but I see death eventually as being great after a certain stage. My mother, my parents both died in their early sixties, and they had heart problems, both of them, uh, I thought at first, that I'd be happy to get beyond that, but, uh, the more you have, the more you want.

12. But I have been doing, I have been doing all the things that I hope will work. I've been taking an aspirin every couple of days, and the doctor said that was great. Uh, he suggested that perhaps I should go on estrogen supplements which is something I would do, you know, menopause and uh, I've considered that, but I will do everything I can that's reasonable to extend my life.

13. Researcher: How would you describe your health in general terms?

Participant: Well, as far as I know, reasonably good, uh, I think I've had hypertension to some degree for many many years, and it's now treated.

14. Participant: I mean if I could pass on that easily, without great struggle. Now that's what bothers me is that when I go up to the palliative care [unit] and also the other folks [chronic], what a struggle they're having. Always left in those rooms, moaning and groaning, some of them, and little ladies that have been busy, busy, busy all of their lives, just sitting there, wanting to do something. God, I thought I hope I'm not going to go through that. You know, that's what scares me. That part.

Researcher: The discomfort? or just?

Participant: Well, not discomfort, but what am I doing here, why am I here. And that's my mother, she was in a nursing home for a while. As a matter of fact, she put herself in when my cousin had to go to a nursing home, and then my mother just followed her so somebody would look after her, you know. She was 78 when she went into a nursing home, and I watched her deteriorate, just not much of a life, you know? And that to me, is a little scarry.

Researcher: So it's the purposelessness, or, idleness, or what is it that ?

Participant: Well, its the, I wish I knew about waiting for Godot? You know? That sort of feeling. You're waiting. And my mother used to say, and she was 94 when she died. So she spent a long time away from her [address] home where she'd lived all her life.

...It was just a useless life she was living, because she had been used to being a care giver all her life

Researcher: oh, she'd looked after your cousin

Participant: everybody, and my grandmother and my aunt. She had always been a care-giver.

15. And when I stop, when I'm not able to uh, my husband and I do all the work around the house, and at the cottage, I papered the hall, got my husband away for the weekend, he got away, and I papered the hall, I got a step-ladder, and I thought, it's two stories, you know, and I thought if this goes up, this stays right, and it did [chuckling from both], and so I've done a lot, a lot of things like that. And when I'm not able to do that, and not able to travel is really important, I always want to see what's on the other side of the, you know, the fence, and uh, when I'm no, if I am a care to my children and my spouse, then I'm not going to be anxious to go on.

16. I suppose if I was asked right outright, I'd say, sure, I'd love to live to a hundred, as long as I was able to uh, you know be able to function in a reasonable fashion, you know if I couldn't read, or I couldn't apppreciate what's going on around me then I, certainly I wouldn't want to.

4.(b) Achieving Purpose In The Sphere Of Existence In The Physical World As A Solitary Being

When the participants projected themselves into the sphere of their existence in the physical world as a solitary being in anticipating death of self, they reflected on things that they would like to experience before they died. Previously cited quotations reveal such experiences. Travelling, reading, and enjoying the environment were mentioned, exemplifying purpose and doing things, as interacting solitary beings. For example, one of the participants expressed his planning for something new in his life, a wish to experience a particular hobby before his death:

I would really love at some point I think to have a greenhouse, because I would really like to raise orchids, but uh, I really don't know whether I'm bright enough, when I read about all of these clones and everything else they do, to sort of figure my way out through that stuff.

4.(c) Achieving Purpose In The Sphere Of Relationships

The nature of communication in relationships about the future death served the purpose of preparing the significant people in participants' lives for coping after participants' future death. Participants described gentle reminders, which were often fleeting. For example, one of the participants discussed making her children comfortable with the societal practices related to death, to save the children future difficulty.

An intentional passing on of values was also described. The Christian 'cours de flambeau', or passing of the torch of Christian belief from one generation to another, was described by one participant. Others also expressed the purpose of passing on values:

I hope, and I think my family will always remember me as a good person, you know, my family and friends. And I hope that my children and grandchildren can, will be successful, and sort of learn some of the things that are important in life from me, as a parent. And uh, I know that is happening, and uh, but they're all individuals and uh it's a changing world, you know. There's so many influences, that are outside influences, that affect people, besides, say your work or your family. But just so much information, and so much to know, and it shapes your values and changes your thinking. And I think it's uh, it's a very challenging time for young people to uh, sort that all out and find out what's important for them, and not get into some sort of trap of dependency and problems in living that we see, multiproblem families and uh go from one crisis to another. And uh, uh [my husband] and I have always emphasized truth and honesty and learn how to work, be kind to your parents and friends, respect people, be loyal to yourself; "to thine own self be true", and uh, we hope that that will continue into the next generation, and it seems to be working.

Another participant described setting aside funds to help her grandchildren meet some of the expenses of higher education, and spoke of passing on this value:

I guess if you want people to remember you, I guess I would want my children and my grandchildren to remember that their grandmother really thought that an education was important.

Two of the participants discussed their thoughts about doing tasks with the purpose of taking care of their family in mind. One wanted to avoid having her family look after any excess possessions she had:

Well, I do think you're going to get rid of a lot of the stuff, you know. I know downstairs, I had a tenant downstairs, and she collected and everything; she just died last year. And when I saw all the stuff they had to get rid of for her, you know, the family had to get rid of, you know, I don't want that to happen to me. I don't want to make them responsible for all this junk. So I toss it.

Another discussed his concern about the work he did around the house with his family, and told how he talked to them about it with the purpose of easing the burden on them after he died:

Well, like I'm concerned about the work I do here, like I do all the outside work, I do all the work around the place, the outside part of the house, you know, I'm concerned when I die about my daughter and my wife, they couldn't do it, you know. They realize it, and like my daughter said, well, we'd likely be here a year Dad, then we'd be gone, we'd have to find something easier.

Preparing their family for bereavement was mentioned by two of the participants. One, as has been described earlier, began talking to his wife about dying and death of the palliative care patients to whom he provided volunteered services. This male participant found that his wife gradually became able to discuss her own potential bereavement upon his death and his potential bereavement upon her death. The participant implied that the adjustment to widowhood would be easier for them if they had discussed it or rehearsed it together beforehand.

Another participant also expressed concern about bereavement in the family, although he had not discussed this at length with the family by the time of the interview:

Researcher: In what way do others or could others help you in facing your own death?

Participant: Um, that's again a very human relationship uh scenario, the fact that uh people could appreciate the fact that you were dying and that they were willing to support you through that. And I guess in return you need to do something and help them get through their grief process. And I used to worry that you would have would be that they weren't able to grieve, and just how that would affect them.

Researcher: So it would help if you could sort of mutually move through it together.

Participant: Yeah, yeah I think so, and uh it just makes it uh, and I guess you know that's in those situations where death is a progressive [thing] and there's a time frame. It uh, you know having gone through a scenario not that long ago where it was all very sudden and uh sort of nothing was uh, you know, parts of it were planned in the sense that the prime people aspects had been looked after to a large part. But you know, there was nothing to suggest that this was going to happen or uh, there was nothing sort of going on in that fashion.

Researcher: no lead up

Participant: Yeah. And it made it extremely difficult I think, for the survivor to grieve, uh because there are so many practical issues that are so wrapped up in the thing that are still ongoing. Uh, and I guess the thing you're concerned about is that; you know, the, and you hope when you're not there you don't see it; that they really have taken the opportunity to grieve and come to terms with this, rather than just sort of, you know, carrying on in an onrushing fashion to if anything to try to avoid the situation. Uh,

Researcher: Do you feel like the practical things that have to be dealt with interfere with the grieving in some way?

Participant: Yeah, I think they do, I think it depends, and mind you, that I think depends on the individual and where they put their primary focus, uh, you know there are some people who really focus on the practical, and you know, we have to get the estate settled, we have to do this this this and this. And you know, I suppose in a sense it's great to be involved in the point of view that you don't brood over what's gone on, but on the other hand you really wonder has that individual come to grips with the fact that you know life has changed, that this is not sort of the same scenario that it was before.

4.(d) Achieving Purpose in the Sphere of Existence in the World as a Part of Humankind

Two of the participants projected their reflections on purpose in anticipation of death of self into the sphere of existence in the world as a part of humankind. One commented that: "...We owe it to society to pay back a little bit of what society has given us". In a similar vein, another participant discussed her continuation of her parents' nurturing of the family, and the importance of that to humankind:

You're always a parent. It's somewhat different, but you're always there, and you know, like our parents; and we always saw them as parents. And it was a very important role in that function in our lives, and I think we're very fortunate, we've all, both [her husband] and I have had that kind of experience, you know, strong family ties. And it has helped us, and I think, the whole family unit, it's important to nourish it and uh, it's very fundamental to society and how we grow and succeed as people.

4.(e) Achieving Purpose in the Sphere of Existence after Death

Only one participant projected herself into this sphere to talk about a future purpose, saying:

" _I just wonder what my use is going to be in the other world"._

She viewed her life as a preparation or proving ground for her usefulness in her life after death.

5. The Holistic Experience of Anticipating Death of Self in Healthy Later Life

The holistic experience of anticipation of death of self in healthy later life was a multifaceted phenomenon of creating readiness and achieving purpose through five spheres of being (Figure 1). In the internal sphere of being, the common nature of the experience was creating readiness for death through acceptance of its inevitability by all participants, with simultaneous expression of fear of dying in seven participants. Concern about the mode of dying encompassed the entire span from a future imagined decrease in participants' current level of functioning to their eventual death. Anticipation of death of self was inclusive of anticipation of the mode of dying for these participants. The ideal death was seen as instant. Achieving a sense of purpose in anticipation of death in this sphere was described as retaining independence and not being a burden to one's family.

In the sphere of existence in the physical world as a solitary being, participants created readiness for death through learning how to appreciate the aesthetic qualities of life on earth and developing wonderment at the beauty, and interest in the character of the world. Achieving a sense of purpose in anticipation of death in this sphere came through travelling, reading, and enjoying the environment. The holistic anticipation of death in this sphere took the form of acceptance of feeling regret at no longer being able to experience the world at some future time.

In the sphere of relationships, creating readiness for death included working through common concerns for the ability of their peer friends to cope with anticipation of death and for their families' continued well-being and healthy adaptation to their own future absence. The participants were achieving purpose in anticipation of death of self in this sphere by preparing other individuals, particularly their family, to cope after their death. In addition, the participants were passing on values to the next generations of their family.

In the sphere of existence in the world as a part of humankind, participants sought inspiration for creating readiness for their death by: reflecting on examples of others in humankind creating readiness; projecting concern about no longer being able to contribute to humankind after their death; and expressing concern about the ability of others to create their own readiness for death. In achieving purpose, in anticipation of their death, the participants reflected and projected their existence in the world as a part of humankind. They developed the sense of having made a positive contribution through making the world a little better because they had lived in it.

Continuing to exist in some unknown form was common to all the participants as they created readiness for their deaths through projecting the thought of themselves in the sphere of existence after death. Four participants reflected on the comfort that their religion gave them in contemplating their own death. Two of these individuals were among the three who also related their unease at what to expect after death. Achieving purpose through the process of anticipation of death of self in the sphere of existence after death was conveyed by two participants who were deeply religious. These individuals talked about future purpose, relating curiosity in their anticipation of what their experience might be in that sphere.

Figure 1 portrays the ongoing process themes of creating readiness and achieving purpose through the five spheres of being apparent in the experience of the anticpation of death of self, as described by the participants in this study. The ongoing processes occur through time during which reflections take place simultaneously on one or more experience, at one or more time, and in one or more spheres of being. The simultaneity of projection into more than one sphere of being is also conveyed in the diagram. The integrating of reflections and projections is portrayed as occurring in the sphere of internal being. The spheres of being are ordered according to the progressive projection of the inner being out into the world external to the individual.

6. Summary

In this chapter, the data collected in this research have been presented. In summary, these healthy participants in later life were anticipating their own death. The participants portrayed their experience in two major process themes, creating readiness for death and achieving purpose in life in anticipation of death. These two themes were described in terms of reflecting and projecting in five spheres of being.

Return to Table of Contents
CHAPTER TWO: OUTLINE OF THE PROBLEM

This study explored the experience of anticipating death of self in healthy later life. In this [first] chapter, background information concerning the need for this exploration is provided, following which the statement of the problem, the study purpose, and the research question are identified.

1. Background and Significance

A common assumption in the nursing profession is that nurses need a holistic understanding of their clients in order to participate in their care (Oiler, 1982). Since, in later life, death is universal, it may be that some form of anticipation of death of self is a universal experience for older people. Thus, an important element of nurses' holistic understanding of older adults is the way that they anticipate their death.

Warren (1989) and Tomer (1992) both discuss two fundamentally opposed viewpoints concerning anticipation of death of self which are found in the philosophy literature. One viewpoint is that being conscious of the inevitability of one's own death can give life meaning and can engender a feeling of wholeness. Another view is that death cannot be experienced because the person no longer exists when it occurs, and that contemplation of death causes anxiety since death reduces one's life to meaninglessness. It is possible that this difference of approach is echoed outside philosopical circles in the thoughts of individual older people.

Religion has played a large role in mediating contemplation of human death. As Axelrod (1986-87) noted, "answers to the fear of non-being constitute religion's primordial statements" (p.52). Similarly, Kastenbaum (1987-88) noted that: "the most compelling and influential views of death seem to have developed within the context of religious experience" (p. 403). Individuals may have different approaches to the anticipation of their own death because of religious differences. Even for individuals who share the same religion, individual experiences may differ.

Although there is no conclusive research evidence about the nature of anticipation of death of self in later life, literature in the field of psychology does illuminate this topic. It is thought that the older one gets the more one thinks of death, and that recognition of mortality grows slowly from middle age and becomes strong in the seventies (Marshall, 1986). Butler (1974) conjectured that since old age is the only time in life with no future, a major task in late life is learning not to think of one's own future. Hans Feifel (1969), one of the first researchers to address death issues in older persons, speculated that their reaction to impending death may depend on their individual psychological maturity.

In his developmental model, Erikson (1963) postulated that the development of ego integrity in the last stage of life is a consolidation in which "death loses its sting" (p.269). In a later work (Erikson, Erikson & Kivnick, 1986), Erikson and his colleagues summarized their thoughts after many years of interviewing people of all ages. "Although an individual life may be cut short at any moment, in childhood, youth, and middle age, the normative expectation is of a future that will last for decades. In old age, however, the duration of the future is far more uncertain. Earlier life's illusions of unlimited time are buffeted by the swelling certitude of mortality" (p.64). Erikson et al. (1986) noted that some older people have difficulty adjusting: "after a lifetime of planning, of sacrificing today's pleasures for tomorrow's anticipated rewards, they struggle to accept the realistic uncertainty that makes this lifelong behaviour pattern suddenly inappropriate" (p. 65). Those who are able to make this transition develop what the authors identify as the final stage of psychosocial maturity: "it is through this last stage that the life cycle weaves back on itself in its entirety, ultimately integrating maturing forms of hope, will, purpose, competence, fidelity, love, and care into a comprehensive sense of wisdom" (Erikson et al., 1986, p.55-56). Erickson et al. (1986) theorize that those who do not develop this final state of integrity become despairing.

In early psychological work, contemplation of death by older adults was viewed as abnormal (Rhudick & Dibner, 1961) or inconsequential (Swenson, 1961). A significant assumption found in the literature is that fear of death is universal among humans (Gilliland & Templer, 1985-86). Much of the work that has been done since these early studies assumes the association of death with negative emotions, such as fear or anxiety or concern (Franke & Durlak, 1990; Kastenbaum, 1992; Thorson & Powell, 1992). Additionally, most of the scales available examine feelings about the actual event of death (Ross & Pollio, 1991), and there is no attempt to evaluate the nature of the experience of anticipating death of self.

In a comprehensive review of the current knowledge concerning death studies, Robert Kastenbaum (1992), the editor of the prominent journal on death and dying entitled Omega, observed that the literature contains a well-mapped developmental picture of childrens' concepts of death (culminating about age 10 with an awareness of inevitability, universality, and finality). Kastenbaum (1992) noted that, in contrast, no similar work has been done with older adults. There are no longitudinal data to show the development of adult constructs or the conceptual structures and processes achieved by adults (Kastenbaum, 1992). Kastenbaum (1992) criticized the bulk of the research done on death anxiety as being superficial administration of a simple self-report scale to an opportunistic sample. He stated that such research is "guided by no clear social utility goal and no particular frame of reference, with data analyzed and presented in a simple and stereotyped manner, and with no firm link established between Death Anxiety score and either antecedent or subsequent behaviour in real-life situations" (Kastenbaum, 1987-88, p. 398). "Exclusive reliance on fixed-choice death anxiety scales will never find evidence for any psychological response other than anxiety" (Kastenbaum, 1992, p.143). In discussing the field of thanatology, Kastenbaum (1987-88) noted that there is inadequate practical implementation of death anxiety research findings and theories. Lester and Templer (1992-93) also found the death anxiety research to be very limited, and they found research on treatment of existent death anxiety to be particularly sparse.

Kastenbaum (1992) stated that anticipation of death is currently viewed as a source of individual destabilization, the effects of which may be amenable to intervention. Kastenbaum (1992) also noted that death research is concentrated on those who are terminally ill: "how people orient themselves to death when there is a salient and objective threat is a significant question...; an equally provocative matter [is] - how do we think about death in the midst of daily life, when there is no obvious, pressing, extraordinary threat to our existence?" (p.134). Similarly, Marshall (1975) wrote that "the problem of thanatology as applied to the developmental psychology of aging is to assess the impact on the everyday lives of aging individuals of their recognition of their finitude" (p. 114).

What can be gathered from these disciplines is that anticipation of death of self is a fundamental and important issue in later life. The study of theories and conjectures alone, however, is of insufficient assistance to the nurse facing an older client. There needs to be an exploration of the patterns of thought which may be found in any older person. Nurses who are aware of such patterns may talk comfortably with older clients, and may be better able to support them as they work through their feelings about any experiences of anticipation of death in later life.

2. Statement of the Problem

The proportion of older persons in the population, specifically those 65 years of age and older, is steadily increasing, and is expected to arrive at approximately 20% by the second decade of the twenty-first century (Marshall, 1987; Beckingham & Dugas, 1993). Furthermore, American statistics show that 70% of all deaths of older people take place in hospitals and nursing homes (Dickinson, Sumner & Frederick, 1992). One obvious implication is that these deaths take place in the presence of nurses. The delivery of nursing care to such a large group of older people necessitates that nurses have a good understanding of the experience of death in later life, and its anticipation.

The experience of anticipating death of self in later life has not been adequately addressed by the nursing profession in relation to nursing assessment and care of older people. In one reference for nursing diagnoses, impending death of self was listed as a factor related to anticipatory grieving (McFarland and McFarlane, 1989). In another such reference (Carpenito, 1989), the fact that the older person may be "facing inevitable illness and death of self and significant others" (p.833) was mentioned in an assessment guide, and as a contributing factor to anxiety. The reactions of anticipatory grief and anxiety may be too limiting to describe the variety and depth of adaptation and adjustments in thinking which may be involved in the development of anticipation of death of self.

In a gerontological nursing text (Miller, 1990), older people were portrayed as becoming aware of their own mortality, and as having life events and adjustments more likely to be losses, rather than gains. The possibility of a positive effect of anticipation of death of self was not considered. In another publication (Beckingham & Dugas, 1993), a discussion of the biological, social, psychological losses, and sources of stress for elders, did not include anticipation of death of self as a possible stressor or factor.

The inadequacy of nursing's present approach was illustrated by one discussion of gerontology in the nursing curriculum, which suggested that nurses sometimes avoid caring for terminally ill older people because death is so frequent (Gioiella, 1986). A more client-centred focus, however, demands discussion of the development of an older individual's constructs about death. The knowledge of such constructs, if they exist, may help to transcend student nurses' reluctance to caring for dying older persons.

Another reason to increase understanding of anticipation of death of self in later life is that older persons are now being asked in some locales to complete and update advance directives for care (Molloy & Guyatt, 1991), which is a major task in preparing for death of self. Nurses (or others) may be asked to approach people in many settings, particularly older persons, to discuss treatment options for various hypothetical future health conditions. The intent of this practice is to have individuals make decisions which are potentially of a life and death nature, in advance of actual illness. Doing so would allow individuals' wishes to be followed even in the event that they were no longer able to communicate. One example of the use of advance directives is a chronic care role study, completed for the Ontario government's Ministry of Health. This study recommended that advance directives should be a component of the patient profile for every admission to a chronic care facility in Ontario (Chronic Care Implementation Task Force, 1995). Additionally, the American government's Patient Self Determination Act of 1991, requires health care providers in medicaid and medicare programs to educate clients in specific programs about living wills (Storch & Dossetor, 1994).

Advance directives can be a major gain for people looking for self-empowerment when interfacing with the health care industry, in the event of a life-threatening illness. However, according to the literature, while most people approached were pleased with the opportunity for such decision-making, others refused or found the process quite upsetting (Molloy & Guyatt, 1991; Stephens, Baab & Castleman, 1991; Bailly & DePoy, 1995). Most often, nurses would not know in what manner the individual is anticipating death of self, or whether there may be patterns to the development of such anticipation which may be common in the population of older persons.

The problem of understanding the anticipation of death of self in later life is that no research has explored older persons' experience of anticipating their own death. Nurses, however, continue to be required to interact with older people in the completion of advance directives for their desired care at the time of dying. The effectiveness of these and all other nursing interactions with older clients may be improved if the phenomenon of anticipation of death of self in later life is known to the nursing profession. If there are common themes in this experience, nurses may be able to distinguish positive acknowledgement of death from severe death fear and anxiety. This would facilitate the ability of nurses to develop appropriate individualized approaches for each client.

3. Study Purpose

The purpose of this investigation was to describe the anticipation of death of self in healthy older persons. The focus was death at some uncertain point in later life, rather than impending death as a result of a diagnosed terminal illness. For this reason, the criteria for purposeful sampling in this study excluded the terminally ill. A phenomenological methodology was selected to explore how older adults actually experience anticipation of death of self. Ultimately, the study was intended to illuminate insights which may enhance nurses' understanding of this phenomenon, so that they, in turn, may use this understanding in their interactions with older individuals.

4. Research Question

The specific research question to be investigated was: How do healthy older persons experience the anticipation of death of self?

Return to Table of Contents
CHAPTER THREE: LITERATURE REVIEW

In this chapter, research on anticipation of death by older persons from both the nursing and the psychological literature is examined. Computerized searches were completed on Psychlit, Medline and Cinahl. Topics searched were "aged" or "elderly", and "death", and "attitude" or "anxiety" or "fear" or "concern". Hand searches were done of earlier references which predated computerized cataloguing. The following sections present an overview, including: the earliest work investigating death attitudes as abnormal thought; death attitudes of fear and anxiety; death attitudes in relation to a number of other personal attitudes and attributes; death attitude as one of disinterest; and most recently, studies investigating death attitudes as experienced by the individual.

1. Earliest Work

In his account on the way older persons look at death, Herman Feifel (1956) claimed to be the first in the psychological literature on this topic. The respondents in his research were 40 male veterans of World War I who were permanently hospitalized in a Veteran's institution due to physical impairment, and whose average age was 67 years. The questionnaire, with prearranged response categories, limited the data received from respondents. Results were inconclusive, with no clear commonalities in the responses. Forty percent saw death as the beginning of a new life, forty percent saw it as the end of life, ten percent saw it as a relief from suffering, and ten percent were undecided. Similar lack of agreement was found to questions about what happens after death, frequency of thought about death, when and of what cause death would occur to them as individuals, and whether or not death was feared in old age. Concurrence was found on two questions: almost all wanted to die quickly with little suffering; and, a smaller majority saw old age in negative terms.

The meaning of the anticipation of death for this group may not have been the same for elderly individuals who would have had fewer physical emcumbrances on their lifestyle. Furthermore, no questions were asked regarding whether or not anticipation of death acted as an organizing principle for living, although Feifel (1956) identified this as an area of needed investigation.

2. Study of the Contemplation of Death as Abnormal Thought

Rhudick and Dibner (1961) measured the extent of death concern for 58 volunteer participants aged 60-86 years, by using a thematic aperception test. These researchers compared their findings to their subjects' scores on the Minnesota Multiphasic Personality Inventory (MMPI). Results on a thematic apperception test revealed a median score of 4 out of a possible total of 24. The researchers concluded that those who scored higher than 4 had high death concern, and that those individuals also had somatic and neurotic symptoms, as indicated by the MMPI. In using the MMPI, Rhudick and Dibner (1961) revealed their preconception of contemplation of death as evidence of mental instability, rather than as appropriate thinking for individuals approaching death, an assumption made in Feifel's (1956) research. No information was provided about control scores on the thematic apperception test, nor were comparisons with other measures of death concern provided to justify equating a score of 4 out of 24 with "high death concern".

Rhudick and Dibner's (1961) study may be compared to a secondary analysis by Bermann and Richardson (1986-87), who randomly sampled 1,428 people from a large 1957 study representative of the adult population in the United States, and from its 1976 replication. The 1957 and 1976 studies also used a thematic apperception test, although with cards different from those chosen by Rhudick and Dibner (1961) from a common standardized set. In Bermann and Richardson's (1986-87) secondary analysis, the proportion of respondents who introduced death into their stories for the cards was 4.3% in 1957, and 7.4% in 1976. In the older age group (aged 55 and above), the percentages were 4% and 6%, respectively. While age groups were not analyzed separately, some indicators of psychological anxiety and physical health were significantly related to a tendency to include death as a theme. These results represent a superficial picture of a possible relationship which would be improved by a richer explanation from participants.

Templer (1971) developed a Death Anxiety Scale (DAS) questionnaire in research which compared scores on that scale with the depression scale of the MMPI and the Cornell Medical Index (CMI), which gives scores on somatic and psychiatric health. Respondents, aged 51 to 92 (mean = 69.7 years) were randomly selected from a list of retired employees. The return rate of 30% yielded 75 anonymous questionnaires. Statistically significant positive relationships were found among the DAS, the depression scale of the MMPI, and the psychiatric scale of the CMI, but not with the somatic scale of the CMI. Templer (1971) concluded that "death anxiety is usually related more to degree of personality adjustment and subjective state of well-being than to reality-based factors" (p. 522). Additionally, he suggested that death anxiety should be treated by bolstering defence mechanisms rather than psychotherapy. The validity of Templer's DAS was not established for older adults. Templer tested its reliability and validity on college students and two groups of psychiatric patients (Templer, 1970). The original testing involved embedding the 15 item scale in 200 filler items. Use of the 15 items of the DAS in isolation may also have affected the results of Templer's 1971 study.

3. Study of the Contemplation of Death as Anxiety or Fear

Swenson (1961) surveyed a convenience sample of 210 elderly people with two non-validated tools: a check-list of attitudes toward death, and a six-item forced-choice rating scale of attitudes to death. Clustered responses on the attitude checklist indicated that 39% looked forward to death, 34% were evasive, and 27% could not be grouped because of seemingly contradictory responses. On the attitude scale, 46% were rated as having a positive attitude toward death, 26% were rated as 'active-evasive' ("just don't think about it"), 10 % were rated as fearful, and 18% were rated as 'passive-evasive' ("none of these fit my feelings"). By giving the respondents personality labels concerning evasiveness, the author interpreted more into his results than his instruments permitted. The variability of the responses and the small number (10%) of respondents who chose to link their attitude toward death to the term 'fearful' suggest that anticipation of death may not be a fearful experience. However, the use of a non-random sample and unvalidated tools make it difficult to generalize these results.

Jeffers, Nichols and Eisdorfer (1961) found, from a convenience sample of 260 community volunteers aged 60 and over, that 90% reported that they were not afraid to die, while 10% indicated that they were fearful of death. The authors gathered their data by asking 'Are you afraid to die?' during the course of a two-hour social history review. Framing the question with the element of fear included may have evoked a defensive reaction on the part of the respondents, and limited the respondents' ability to relate their full range of attitudes to their future death.

Bengston, Cuellar, and Ragan (1977) researched the association of death orientation with social strata, race, age, occupational status and gender using a stratified random sample from the census of Los Angeles county. The participation rate was 80%, which reflected a final sample of 1,269. Questions about attitudes to death were three items out of a total of 150 items on the entire questionnaire administered to the respondents. Findings indicated that the only significant difference in expressed fear of death was in the age groupings. The older age group expressed significantly less fear of death than the two younger groupings, irrespective of race and socioeconomic status. The difference in gender approached significance, with females tending to be more fearful than males. Only 9% indicated that they frequently thought about their own death. The older the respondents were, the fewer years they predicted they would live. Whether this was related to death attitude or orientation, or awareness of finitude, was not analyzed.

Sanders, Poole and Rivero (1980) randomly selected 62 seniors (aged 60-87 years) from rural Mississippi, half of whom were black and half white. Using the Death Anxiety Scale (Templer, 1970) the researchers determined that blacks had significantly higher death anxiety than whites, and that females had significantly higher death anxiety than males. The authors attributed the racial difference to a greater tendency toward superstition among blacks. Both the small sample and generalization of difference in race, without due consideration of the cultural milieu of the participants, limit the usefulness of these findings.

Kurlychek and Trepper (1982) compared the responses of a small convenience sample of college students (23, aged 18-22) and seniors (21, aged 60 and over) on a 'purpose-in-life' scale and the Collett-Lester Fear of Death scale. The seniors scored significantly higher on the purpose-in-life scale, and significantly lower on the fear of death scale than did the students. While this study has congruence with other studies which indicate that fear of death of self is lower in the elderly, the inadequacy of the sampling constitutes a main weakness.

Mullins and Lopez (1982) used Templer's Death Anxiety Scale to attempt to differentiate between the young-old (65-74) and the old-old in a sample of 225 nursing home residents. Results indicated that 38% of the young-old had high anxiety (scoring 50 or higher to a maximum of 75), while the old-old experienced significantly more death anxiety (59%). In the young-old, high death anxiety was associated with poor subjective health, poor functional ability, a longer length of stay in the nursing home, and lack of social support. In the old-old, poor subjective health and poor functional ability were positively associated with high death anxiety. No relationships were found between high death anxiety and gender or educational attainment. Study findings indicating high death anxiety in the aged contrast with results of other studies reviewed. The approach to administering the questionnaire, the nursing home context of study subjects, and/or their physical health status may have contributed to this differing experience.

Stricherz and Cunnington (1981-82) administered a forced choice questionnaire to 86 respondents in each of three age groups (mean age in the three groups was 16.3, 42.5, and 68.9 years respectively) of non-randomly chosen volunteers, to assess death concern. Each of the 15 questions began with the phrase "I am afraid", and respondents were asked to choose the five items that most accurately represented their feelings. Seniors' responses reflected their fear of being helpless and dependent when dying, having pain when dying, and taking a long time to die. The non-random choice of participants, and the questionnaire's intentional focus on fear, limit the usefulness of the results of this study.

Fry (1990) identified a need to know more about the attitude of the elderly toward death. However, her nursing research was also firmly couched in terms of fear of death and death anxiety. The respondents for this study were 198 elderly persons (aged 65.5 - 87.3 years, mean = 70.8 years) who were selected randomly from Meals on Wheels recipients and home health services in Western Canada. Using a semi-structured questionnaire, Fry asked what aspects of death and dying caused concern, fear, and anxiety. The common themes in the responses were fear of dying alone, fear of being permanently forgotten after death, and uncertainty about the existence of life after death. The predefined emotions explored in this study also effectively ascribed the meaning of death as the respondents were not given the opportunity to explain a different range of emotion other than fear and anxiety in the contemplation of death.

Lavigne-Pley and Levesque (1992) studied the reactions of elderly nursing home residents to the deaths of their peers. A convenience sample of 25 elderly residents, with an average age of 80 years, answered a semistructured questionnaire. Residents responded that they thought that nursing staff were indifferent to the deaths, as they did not inform other residents of the imminence or the fact of the deaths. When asked if they thought of their own death as a result of the death of a peer, some residents indicated that they found it too painful to discuss. Others indicated that they were prepared for death, so the death of a peer did not affect thoughts of their own death. Half said they did not fear death, the others talked about fear of what would happen at the time of dying, rather than fear of being dead. In this study, researchers made assumptions about the variables which may contribute to the experience being examined, thereby precluding valuable information about individuals' real experience (Morse, 1991).

4. Studies Relating Level of Death Anxiety to Other Attitudes or Personality Characteristics

Durlak (1973) used his own "fear-of-death" scale and "purpose-in-life" scale with thirty-nine female residents of retirement or nursing homes (mean age = 76 years) in Germany. He designed this research to study a philosophical assertion that the basic motivation in humanity is meaning in life, and that this meaning is found in the context of accepting the fact of one's future death. Results indicated that there was a significant negative correlation (r = -0.38, p<0.02) between purpose in life and fear of death.

Nehrke, Belluci, and Gabriel (1977-78) tested Erikson's theory of the final maturational stage (ego integrity versus despair) by administering four scales (life satisfaction, locus of control, fear of death and death anxiety) to 120 people, 20 men (mean age = 73.3 years) and 20 women (mean age = 74.8 years) from each of three living settings (general community, public housing, and nursing home). The authors found no relationship between ego integrity, as measured by life satisfaction and locus of control instruments, and death anxiety and fear of death. Therefore, Nehrke et al. (1977-78) were unable to confirm the hypothesis that those with high ego integrity had lower fear or anxiety, which would have been congruent with Erikson's theory.

Bascue and Lawrence (1977) studied the relation between death anxiety in older women and their subjective approach to time. A convenience sample of 88 women from two different seniors' apartments (one in D.C., the other in Virginia), completed Templer's Death Anxiety Scale and a scale of religious development. The approaches to time assessed were: time anxiety, or a need to control time and a dependence on objective measures of time; time submissiveness, which indicated a conforming attitude toward time; time possessiveness, which was indicated by disturbance at the quick passage of time and a need to know about the future; and, time flexibility, or a relaxed attitude toward subjective time with little anxiety toward losing track of objective time. Results indicated positive significant correlations between the "anxious" attitudes toward time and death anxiety, but no relation to a relaxed attitude toward time. It is possible that the reason for the positive correlations in this study was the relation of all the scales, except time flexibility, to a general anxiety level. At the time of its validation, Templer found that the Death Anxiety Scale was positively correlated with two measures of general anxiety at the 0.5 level of significance (Templer, 1970). The correlations of the religiosity scale to the death anxiety scale were insignificant, in contrast to the results from a study by Koenig (1988).

Baum and Boxley (1984) surveyed a convenience sample of 301 volunteer elderly people from the Los Angeles area (mean age was 75.5 years), asking them to report whether they felt younger, older, or the same as their true age, and to complete a modified version of Templer's Death Anxiety Scale. There was no identified relationship between age denial and fear of death. Those who were single, those who had poorer emotional health, and those who felt externally controlled had higher scores on the death anxiety scale.

Koenig (1988) surveyed a non-random sample of 304 ambulatory and home-bound elderly to investigate the relation of religious beliefs, social activities within the religious community, and fear of death. Those respondents who were likely to use religious prayer and beliefs during stress were significantly less fearful of death than those who did not. Those who had a high level of involvement in the religious community were less likely to express fear of death, although the results were not statistically significant. In the group aged 60-74, 55.1% reported no fear of death, and in those aged 75-94, 44.3% reported no fear of death. Those who had both religious beliefs and a high level of activity in the religious community were significantly less likely to report fear of death than those who were not.

Koenig's (1988) study was strengthened by a large sample, and by demographic comparison to the population which allows the reader to judge the results. However, the low response rate (43%) and the unidimensionality of the feelings toward death (no fear, some fear, moderate fear and high fear) limited the depth of understanding of the attitudes of elderly people. Ninety-four percent of the respondents adhered to the Christian religion, which includes belief in life after death and reward for a life well-lived. Thus, being asked about religion and fear of death in the same questionnaire may have led the respondents to claim less fear of death in order to be consistent with expections in the Christian faith.

Gesser, Wong and Reker (1987-88) attempted to validate a scale which included items relating to five dimensions of death attitudes: negative thoughts and feelings about the state of death, negative thoughts and feelings about the process of dying, thoughts of death as a passageway to a happy afterlife, death thought of as an escape from a painful existence, and death accepted with neutrality (neither feared nor welcomed). Results indicated that the elderly were significantly less afraid of death and dying than the middle aged, and less afraid, but not significantly so, when compared to younger adults. The elderly were more accepting of life after death and the reality of death as compared to all younger respondents. However, the difference between the elderly and the middle-aged was not statistically significant.

Gesser, Wong and Reker's (1987-88) study was limited to the dimensions constructed by the researchers, rather than the elderly respondents themselves. Scale development was limited by the number of respondents used to classify the items (12 in each age grouping), and assignment of items to the categories by agreement rather than by factor analysis. Additionally, the ultimate study sample was also small (50 per age group), and no information was given as to how respondents were chosen.

Cataldo (1989) used the scale developed by Gesser, Wong and Reker (1987-88) along with measures of hardiness and depression in a study of 46 female and 44 male residents of a skilled nursing facility in New York City. Respondents' average age was 73.3 years, and average length of stay in the nursing facility was 41.3 months. Cataldo found that there were statistically significant correlations (p<0.05) between the residents' hardiness scores and depression scores, and depression and all death attitudes, except approach-oriented death acceptance. The author concluded that a person who was not only hardy, but also had a positive attitude about death, may be less vulnerable to depression. Although Cataldo (1989) did not explicitly identify cause and effect relationships, he implied that the hardiness and the positive attitude to death were present first, and provided a protection against vulnerability to depression. This crossectional study did not have sufficient information to make a causal claim. It was also possible that depression existed first, and that the factors later measured on the hardiness scale and the death attitude scale were changed as a result of the depression. An additional limitation of this study was the use of Gesser, Wong, & Reker's (1988) "death attitude profile", which was inadequately validated.

In a convenience sample of 30 adults between the ages of 20 and 70, Schorr and Schroeder (1989) found a positive correlation (r=0.47, p<0.01) between death anxiety (as measured by Templer's Death Anxiety Scale, 1971), and Type A behaviour (defined as behaviour manifested by those who are intent on accomplishing the most in the least amount of time). In their conclusions, Schorr and Schroeder (1989) themselves noted a major limitation of the Death Anxiety Scale, the items of which "conceptualize death as an external event associated with a perception of time running out, static and final, rather than an inherent dimension of the unitary nature of life" (p.191).

Rappaport, Fossler, Bross and Gilden (1993) tested the association they had hypothesized to exist between death anxiety, purpose in life, and temporal association for 58 retired respondents (mean age = 73.4 years), who lived independently in one retirement complex. The authors used Templer's Death Anxiety Scale and Crumbaugh's Purpose in Life attitude scale, as well the Rappaport Time Line, which measured the overall temporal orientation of the individual. Results indicated an expected significant negative correlation between death anxiety and purpose in life, a positive correlation between purpose in life and temporal orientation toward the future, and a positive correlation between death anxiety and temporal orientation toward the present. Both the small sample size and the narrowly applied concept of death anxiety limit the overall usefulness of this study.

5. Study of Contemplation of Death as Disinterest

Mitchell (1990) conducted a qualitative study on daily life in a purposeful sample of 10 people aged 75 and over, and found that they had "a liberated sense of self, a quiet disinterest in death, ... choosing what is valued and meaningful while there is time" (p.35). The phrase "while there is time" indicates that the "quiet disinterest in death" reported may be mitigated by the respondents framing their daily life with the anticipation of death. This was not explored by the author. The disinterest in death may also reflect an acceptance of the advent of death, or a desire to avoid prolonged contemplation of death. These aspects need further investigation.

Mitchell described her methodology as guided by Parse's emergent method, which is "based on phenomenology in the generic sense" (Mitchell, 1990, p.30). Mitchell (1990) began the research with a stated hypothesis that older individuals take life day-by-day and do not plan for the future. The respondents were asked to relate the experience of 'taking life day-by-day'. Stating this assumption hampered truly phenomenological interpretation, since 'taking life day-by-day' may or may not have emerged as participants revealed the pattern of their daily lives. The approach limits the usefulness of this study for nurses wanting to gain in-depth understanding of anticipation of death as part of daily life in later years.

6. Contemplation of Death as Awareness of Finitude

In 1975, Victor Marshall proposed that an important element left out of consideration in assessing the psychological processes of the elderly was awareness of finitude. Prior to that point, investigators used age alone as a dependent variable. Marshall suggested that awareness of finitude may be related to age, but may not correspond exactly with it. Marshall asked a convenience sample of 49 healthy, middle-to-upper class white Americans with an age range of 64 - 96 (mean = 80 years) to indicate on a three-item forced choice questionnaire, whether they thought they would live for 10 or more years, 5 to 10 years, or less than 5 years. Findings indicated that the relation of perceived finitude was significantly related to the age of the respondents and with the age of their parents at death. Awareness of finitude and the number of siblings the respondents had outlived were also positively correlated. The survival of siblings was not independently related to awareness of finitude as compared to the age of the respondent.

The personal estimate of the number of years left to live may be an inadequate measure of the 'awareness' of finitude. There may be some individuals who are never unaware of their finitude, or mortality, during their entire adulthood. Therefore, using this numeric index as a dependent variable to examine, for example, whether they are likely to be engaged in life review, will not identify those persons who are never unconscious of past experience and reevaluate their life continuously for many decades of adulthood. The sense of being mortal may be more or less developed in individuals. This may or may not be more pronounced in the cohort which is now elderly when compared to younger cohorts. The task of finding an appropriate dependent variable could be interpreted as an inadequate approach to understanding the complexities of anticipation of death of self, as it causes much rich information to be ignored in favour of a one-time guess about the number of years one has left to live. Furthermore, it is obvious that the longer a person has lived, the shorter is the span of years remaining until they die. In this sense, awareness of finitude as defined as a subjective assessment of how long one has left to live, is not substantially different from one's age.

7. Death as Defined by the Individual

Jones (1993) completed a case study of one woman's death to obtain an understanding of the woman's experience. The research participant was a 67 year-old hospitalized person who was terminally ill with metastatic cancer of the colon. Her husband refused to accept her imminent death, and her health care providers presented palliative measures as curative, thereby creating conflict when they tried to have this woman/participant act through their definitions of the situation. The woman received comfort from those who accepted her interpretation of needs and events rather than redefining them for her. Eventually, in Jones' interpretation, the participant maintained control of her own experience of death by withdrawing into a non-communicative state. The author concluded that a patient's impending death should be treated by nurses within the frame of reference defined by the patient. Although this study involved a dying patient, the insights acquired from the phenomenological approach suggest the importance of acquiring further understanding of the individually defined reality of healthy older persons' anticipation of death.

Gullickson (1993) conducted a Heideggerian hermeneutical analysis of the experience of persons over the age of 65 living with chronic illness. The participants were asked to relate a story which best described what it means to live with a chronic illness. Patterns which were identified included: my death nearing its future, awareness of not being, and death as an event or a possibility. While it is noteworthy that living with chronic illnesses elicited themes related to the anticipation of death, the themes were extracted from published philosophical works, and the raw data were used to illustrate some of the themes. The understanding gained was that of the possibilities of the relation of self to death as developed by Heidegger, leaving many unanswered questions about the in-depth experience of anticipation of death of self.

8. Summary

In this chapter, research related to the contemplation or anticipation of death of self in older people as portrayed in the psychological and nursing literature was presented. Many investigators have researched questions related to anticipation of death in later life, but none has directly asked the older adults to describe their experience of anticipation of death of self in their own words and context. Since most studies cited in this chapter used quantitative methods, in which categories of data are fixed at the beginning with a precise relationship established between these limited preset categories (McCracken, 1988), research to date reflects the assumptions of the researchers. Thus, the anticipation of death of self has been seen as an aberration, as fearful above all else, as a subject of disinterest, and as awareness of time span left to live. The assumption that death is feared permeated most of the correlational studies. Two studies described anticipation of death as defined by the individual, but the focus of these studies was not directly on this experience.

Despite the framework of fear or anxiety which many scales have toward death, the research results revealed that older participants may be characterized as having low death anxiety (Bengston, Cuellar, & Ragan, 1977; Kurlychek & Trepper, 1982), in accord with some early work in which positive feelings toward death were elicited from a majority of the elderly participants (Jeffers, Nichols & Eisdorfer, 1961; Swenson, 1961). Clearly, how older people experience anticipation of their own death requires further investigation.

Return to Table of Contents
CHAPTER FOUR: METHODOLOGY

Nursing research encompasses the patterns, themes and attributes within the natural context of daily life (Leininger, 1985). Recognition of the holism of human experience has led to a movement in nursing to use a qualitative approach to examine the full breadth of human experience (Benner, 1994). The phenomenological approach in this study of the experience of the anticipation of death of self in healthy later life permits the exploration of new areas of knowledge and the achievement of fresh perspectives on traditional views of human experience (Leininger, 1985).

Phenomenology focuses on the question "What is the structure and essence of this phenomenon for these people?" (Patton, 1990, p.69). Phenomenology is valuable in discovering meanings of clinical nursing situations and their relationship to nursing practice (Leininger, 1985). Benner (1994) describes interpretive phenomenology as "a dialogue between practical concerns and lived experience through engaged reasoning and imaginative dwelling in the immediacy of the participants' world" (p. 99).

This chapter consists of an overview of the methodology, the sampling, the data collection method, the analysis and interpretation, the methods of protection of human subjects, the bracketing of the researcher's experience before initiating the study, and the methods of ensuring validity and trustworthiness which are to be used in this research.

1. Overview of the Methodology

Phenomenology is an inductive, descriptive research method (Omery, 1983). The aims of phenomenological research are to investigate and describe phenomena as experienced (Lynch-Sauer, 1985), without attempting to attribute causal explanations (Spiegelburg, 1975; Omery, 1983; Leininger, 1985), and to understand world, self, and other (Benner, 1994). Using the phenomenological method, the researcher may uncover the ground structures, or essences, of phenomena, by analysis of situations (Lynch-Sauer, 1985). Since understanding of the phenomenon develops through the research, no hypothesis is postulated before the commencement of the data collection (Omery, 1983). Similarly, because the findings are wholly derived from the participants, the work is not done from within the confines of a conceptual framework (Omery, 1983).

Within phenomenology, reality is viewed as subjective (Oiler, 1982). The view of phenomenologists is that there is not one external reality or absolute truth; the descriptions of the real world, even those in the physical sciences, are an abstraction of pre-scientific experiences (Hammond, Howarth, & Keat, 1991). Phenomenology has its origin in philosophy, where it was originally developed for examination of the researcher's own perceptions (Spiegelberg, 1975). The method has also been used by groups, and, as a research tool, involves gleaning the experience of others vicariously, rather than by direct perception (Spiegelberg, 1975). Gathering other people's experience allows us to become more experienced ourselves (Van Manen, 1990).

The data in phenomenological research are the verbalized thoughts of participants about their opinions, experiences, feelings and knowledge concerning an issue (Leininger, 1985; Patton, 1990). One basic assumption of phenomenological research is "...that the perspective of others is meaningful, knowable, and able to be made explicit" (Patton, 1990, p.278).

While it is quite likely that each individual participant will experience the same phenomenon in a unique way, another basic assumption of phenomenological research is the existence of similarity in the essence of shared experience (Patton, 1990). "These essences are the core meanings mutually understood through a phenomenon commonly experienced" (Patton, 1990, p.70). Each experience is unique, and the basic elements of the experience of the participants can be identified and described, to gain some understanding of the phenomenon or human experience in question (Patton, 1990).

Heron (1981) refers to this type of research as phenomenological mapping of intrapsychic or emotional spaces within persons. Van Manen (1990) characterizes the individuality of persons by describing the 'lifeworld', a set of different existences and realities that is unique for each person. It is understood that human beings can never be explicated fully, that they continue to change over time (Benner, 1994), and furthermore, that humans are self-interpreting and self-changing (Leonard, 1994).

The findings of phenomenological research are the typical structures or essences, which may exist in the experiences of individuals, and which the researcher is able to discover through inductive analysis of the data (Spiegelberg, 1975). Findings of phenomenological research cannot be generalized beyond the participants (Van Manen, 1990). Instead, findings suggest possible commonalities and differences in culturally grounded meanings which may promote understanding of the phenomenon (Benner, 1994).

Benner (1994) has explicated five sources of commonality which are explored in phenomenology: situation, embodiment, temporality, concerns, and common meanings. The commonality that is explored in this thesis is a concern. Benner (1994) defines a concern as "the way in which a person is oriented meaningfully in a situation"; "what is salient to the person in the situation" (p. 105).

Leonard (1994) notes that although individuals personalize the background meanings in their lives, those meanings are not infinitely variable or totally relative to each unique configuration of individual and situation. There are shared cultural and linguistic meanings which make possible the consensual validation of individual meaning and behaviour. Although individuals are assumed to be unique, and knowing is assumed to be subjective, "private, idiosyncratic meanings" (Leonard, 1994, p.58) do not constitute the findings of phenomenological inquiry.

2. Sampling

The method of sampling used in this study was purposeful sampling. Participants were selected to provide an adequate and appropriate sample, according to the needs of the study for informants who have knowledge of the research topic (Morse, 1991). In keeping with the use of lengthy interviews, the sample size was small, as is usual for this type of inquiry (Omery, 1983). McCracken (1988) suggested eight as an ideal number. Morse (1989) suggested that participants should be interviewed until there is saturation of the data; that is, there is no new information being elicited. The eight participants in this study constituted an adequate sample since the small number facilitated the collection of a large amount of data from each individual. No new themes were apparent after the fourth interview, indicating that the point of data saturation had been reached. However, the richness of the data gathered from all eight facilitated the deep description of the themes.

Since the aim was to study the experience of individuals as they approached the end of the human life span, the participants in this study were limited to healthy individuals above the age of sixty-five. The study was concerned with the healthy state, or smooth functioning of life when one is an older adult, rather than being focused on the breakdown of functioning, or the advent of disease; an important distinction to make (Benner, 1994). All the participants in this study were asked to self-report their own opinion of their health status, and all stated that they perceived themselves to be healthy.

The participants also needed to be 'good informants', knowledgeable about the subject matter, reflective and articulate, and willing to share their thoughts with the researcher (Morse, 1991). Referrals to suitable individuals were sought from colleagues and acquaintances, and some individuals were approached directly. Initial approach involved a brief verbal description of the research. If the potential participant agreed to consider participating, they were given, or mailed, a 'Letter of Information' (Appendix A), a 'Letter of Introduction' (Appendix B), a form on which they could indicate their decision whether to participate (Appendix C), and a stamped envelope addressed to the researcher at her home. Of the twelve people who were approached indirectly and agreed to consider participation, seven accepted and were interviewed. Of the five who were approached directly, three refused. Of the two who accepted, one was interviewed; however, the schedule of the other prevented arrangement of a time for an interview.

The eight participants were fluent in English, since that was the language of investigation (Omery, 1983). Intact memory and reasoning skills were also necessary requirements for participation as the participants needed to understand and express their inner feelings (Le Compte & Goetz, 1982; Omery,1983; McCracken, 1988). Sufficient ability of the respondents to communicate with the researcher was essential, since the first step in the analysis of the experience of others was the translation of that experience by the respondents into language (Lynch-Sauer, 1985).

To maintain a consistent cultural identity of the participants (McCracken, 1988), those participating were all residents of Canada. Seven of the participants had lived all their lives in Canada, the eighth had lived in Canada for 32 of his 65 years. Men and women were equally represented numerically as it was important to ensure that findings illuminated any similarities and/or differences between genders on attitudes toward death (eg. death anxiety) (Kalish & Reynolds, 1981; Marks, 1986-87; Koenig, 1988). The eight participants were aged between 65 and 69 (mean = 66.75) years. In the process of purposeful sampling, the sampling frame characteristics led to the decision to maintain homogeneity in religious orientation within one religious context, Christianity, in order to contain the scope of the study. All participants were raised as Christians and all remain active in the Christian faith.

3. Data Collection Method

The sources of the data are the people who live the experience, and their presentation of their experience to others constitutes the data (Oiler, 1982). Using a semi-structured interview guide, (Appendix D) the data were gathered through lengthy interviews (Omery, 1983; McCracken, 1988) which were recorded on audiotape. The researcher took notes on observations of nonverbal aspects of the data (Oiler, 1982), such as the setting and the expression and body language of the respondents, keeping note-taking to a minimum to avoid distraction (McCracken, 1988). The interview was conducted with only the researcher and the participant in the room, as interviewees tend to vary what they say, depending on who else is present (Le Compte & Goetz, 1982).

Data were collected by posing questions to the respondents to give "the barest minimum of a sense of direction" (Oiler, 1982, p.180). Unobtrusive questioning in a general, non-directive, non-judgemental manner encouraged the participant to formulate the response without the interviewer influencing the content (McCracken, 1988). The language used in the questions was conversational, rather than abstract or academic (Benner, 1994).

A semi-structured questionnaire (Appendix D) and a constructed series of prompts assisted in the orderly collection of qualitative data (McCracken, 1988). Spiegelberg (1975) described this as sympathetic probing. Benner (1994) described probing as a method to ensure that understanding has occurred. The use of the questionnaire accomplished three things: it ensured that the subject matter was covered for each respondent; that the prompts were easily available, allowing the interviewer to concentrate on the interview; and that the direction of the discourse was channelled (McCracken, 1988). Using the long interview permitted the researcher to collect data for a thorough qualitative analysis, without the time-consuming practice of participant observation or prolonged immersion and contact with the participants (McCracken, 1988).

The setting in phenomenological research is always a natural setting for the participants, rather than a laboratory (LeCompte & Goetz, 1982; Omery, 1983; Leininger, 1985). Accordingly, interviews were conducted in the homes of the participants, in whichever room they chose (seven were in the living-room; one in the dining-room). The times and dates arranged for the interviews were set by the participants.

4. Analysis and Interpretation

In qualitative research, the researcher becomes an instrument of the research, by sorting and analysing the data, and searching out patterns of the participants' assumptions and associations (McCracken, 1988). The methodology of phenomenology has been likened more to carefully cultivated thoughtfulness, rather than a technique (Van Manen, 1990). The six steps outlined by Spiegelberg (1970) are: describing, finding the essences, finding the appearances of the phenomenon in various perspectives, exploring the way the phenomenon takes place in consciousness, suspending belief in the reality of the phenomenon to naively examine the content, and interpreting the concealed meanings of the phenomenon.

In order to describe, the researcher immerses himself or herself in the entire descriptions of the participants to get a sense of their experience (Omery, 1983), transforming the language of the respondent into an understanding (Lynch-Sauer, 1985), or 'essence'. Van Manen (1990) describes essence as a linguistic description of the phenomenon. The researcher identifies, or intuits, the constituents or essences of the experience (Omery, 1983) from the descriptions.

In this process, the researcher uses bracketing, or phenomenological reduction, which is accomplished by suspending belief in the phenomenon in question in order to explore it naively, without preconception (Spiegelberg, 1970, 1975). Intuiting the essences consists of looking at the data naively, bracketing other knowledge, facts and theories (Oiler, 1982). Intuiting the essences requires shuttling back and forth between the concrete examples, and the abstract, or imaginative insight (Spiegelberg, 1970; Van Manen, 1990). In intuiting essences, the researcher asks whether the phenomenon remains unchanged if any descriptive essence is removed (Van Manen, 1990). Grasping an essence or theme is not a rule-bound process, but a free act of insight or 'seeing' meaning in which a phrase is discovered to describe the experience (Van Manen, 1990).

The researcher then clarifies the essences of the experience, eliminating redundancies and internal contradictions in the description. The relations of the constituents of the experiences to each other, and to the experience as a whole, are established (Omery, 1983; McCracken, 1988). The essences of the experience must be backed by specific examples (Spiegelberg, 1970). The researcher transforms the language of the participants into 'scientific' language and "synthesizes the insights into a descriptive structure of the meaning of that experience" (Omery, 1983, p. 58), which is a powerful description and fertile in its insight (McCracken, 1988).

The final step is the transformation of the synthesis into an understanding by the reader (Lynch-Sauer, 1985). A phenomenologically powerful description, containing appropriate and thoughtful essences, permits us to understand the deep significance, or meaning, of the experience (Van Manen, 1990). The description of the experience is enhanced through thematic analysis (of the essences), paradigm cases, and exemplars (Benner, 1994).

"The phenomenological inquiry is not unlike an artistic endeavour, a creative attempt to somehow capture a certain phenomenon of life in a linguistic description that is both holistic and analytical, evocative and precise, unique and universal, powerful and sensitive" (Van Manen, 1990, p.39). The interpretation of the data is not considered more truthful than the data themselves; rather the interpretation provides a deeper understanding of the data and of the phenomenon to the reader (Benner, 1994). In analysis, the commonalities are not assumed to be driven by any form of logic or rationality, and are not analyzed according to any theory; instead, the researcher hopes to have the commonalities articulate previously poorly understood experience (Benner, 1994).

5. Protection of Human Rights

The research protocol for this study was approved by the Review Board for Health Sciences Research Involving Human Subjects at the University of Western Ontario (see Appendix F). In conducting this research, participants' right to self-determination and fair treatment was upheld by freedom of choice to participate in the study, and freedom to cease participation in the study at any time during its course. The right to privacy was maintained by keeping the information shared by the participant confidential and anonymous. Data were stored where access was limited to the researcher, and stored without information that would identify the participants. The participants' rights to protection from discomfort (as evidenced by evasion, embarrassment, verbal statements of unwillingness to discuss the topic, facial expressions of emotional discomfort) and harm were addressed by assessing their level of comfort throughout the interview and evaluation processes. All participants were reminded that the interview could be stopped at any time, as written in the 'Letter of Information' (Appendix A). Two of the participants cried briefly and another seemed uncomfortable at one point during the interview. At such times, the offer to stop was repeated in an open and accepting manner, but was refused. In all the interviews, the conversations were interspersed with laughter and were very relaxed.

If the interviewing is properly conducted, participants in phenomenological research often develop an intense interest in the research question, enjoy a new level of self-awareness (Van Manen, 1990), and experience a benefit from participating in an intense conversation with someone who is quite eager to listen to what they say (McCracken, 1988). When asked how the interview had affected them (the last question), three participants responded that it had not affected them one way or another. Three said that they were really looking forward to participating and enjoyed discussing how they felt. One of the participants described her feelings during the interview as follows:

You really dig down deep inside yourself and explore how you feel, and try to express yourself in a meaningful way. And uh, it's a part of you that's very difficult to share, probably. And everybody sort of has a little area, maybe they guard. Or I don't know what it is, and I can't even describe it any further than that. But you talk about things in depth, and probably in this conversation, in more depth than I would with anybody else. I haven't really shared this much with many people, and I feel good. I feel good. I really feel good talking about it, just sort of shaping the words and listening to myself, you know, and sort of seeing it in greater depth - any time I do it.

Two of the participants had experienced the deaths of contemporaries a few months before the interview, one a sister, and the other, a close friend. One expressed her need to talk and her conviction that participating would help her:

I know that you have to go through a lot, uh, you have to go through a lot of talking... And I've worked with people who have - someone has died, someone close to them. The people who stand back and won't let them touch you, or nothing touches them, I know are going to have a very difficult time. I know that this is part of it and that I will get through it and I will come out. I will never really get over it, but I'll be better than if I had not talked. And I know that this is probably going to help.

The other stated that the interview had helped him clarify his thoughts:

I guess it's affected me in a sense that I've probably put into words or expressed in words a number of things that I've been thinking that sort of that you ruminate on, on an ongoing basis. Uh, I think in a sense it's clarified sort of where you're coming from and where the questions are in your own mind, and the realization that a lot of those questions are not going to be answered.

In summary, the interviews either did not affect the participants, or affected them positively.

6. Declaration of Self in Front of the Text

Interpretive researchers attempt to "bracket" personal views by identifying and laying aside what they already think they know about the phenomenon under investigation (Oiler, 1982). Intimate acquaintance with the culture of the participants can both give insight and create blindness, which may prevent a researcher from seeing cultural assumptions and practices (McCracken, 1988).

Prior to initiating this study, the researcher experienced attitudes of anticipation of death of self in older individuals and those caring for them, while in various clinical roles: as an acute care bedside nurse, a discharge planner, a clinical nurse specialist in geriatrics, and as a clinical manager in chronic care. The researcher came to understand that a predominant preconception held by caregivers was that death was a topic that was too sensitive to be discussed with people in later life, and that there was no need to discuss the prospect of death because it was understood as inevitable in old age and therefore unspectacular. This experience contrasted to clinical observation of the importance given to personal adjustment of a patient and family when a younger person was dying.

Additionally, the researcher came to understand from many interactions with ill older people that, when they mentioned death, and were then listened to and able to express their feelings, these individuals experienced relief. It seemed as though, after such conversations, these older adults felt as though they were being respected. Ill older people seemed very appreciative of the opportunity to discuss their thoughts and feelings about death, and their ability to deal with changes in their health and daily life appeared to improve. Conversations with older people had given the researcher the understanding that the idea of eventual death is more predominant in the daily thoughts of people in later life than it is in younger people.

The researcher came to understand from the literature review that older people may be less anxious about death than younger people. According to the literature, religion may mitigate the attitude of people in later life toward death of self. Older people were also reported to deal more readily with making arrangements in preparation for death than do younger people.

All of these assumptions and preconceptions were identified in order that they could be bracketed while the data were analyzed. This bracketing was accomplished during analysis by repeated immersion in the data without a conscious attempt to order it. When insights sprung to mind unbidden, they were evaluated against the data. The pattern of essences which showed commonality and best provided deep understanding was retained.

7. Validity and Trustworthiness

In phenomenological investigation, the issues of validity and trustworthiness have different parameters than in quantitative methodology. In quantitative research, one reality is assumed, whereas multiply constructed realities, which cannot be generalized, are assumed in the qualitative approach. Therefore, the methods of evaluation used in one approach cannot be used in the other (Lincoln & Guba, 1985).

In qualitative investigation, the quantitative concept of "internal validity" of the research is equivalent to "truth value" or "credibility". Credibility is determined by the extent to which the findings reflect the multiply constructed realities of the participants (Lincoln & Guba, 1985). Credibility in this study was established by prolonged exposure and persistent observation, which permitted the investigator to build trust with the participants and to coinvestigate the experience with the participants in sufficient depth so that the meaning of the experience could be understood. Other methods of establishing credibility of the data included: triangulation, in this instance, by comparing data from different sources; peer evaluation of the inquiry process by the principal advisor; negative case analysis; continual rechecking of findings against raw data; and, "member checking", or testing of the findings by having the participants check the interpretation to assess whether it captures their experience (Lincoln & Guba, 1985).

In interpretive research, the findings should be recognized to be true by those who have lived the experience (Oiler, 1982). Feedback from the participants helps avoid what Patton (1990) refers to as the Type 1 and 2 errors of qualitative research: saying something is not significant when it is, or saying something has significance when it has none. Reason (1981) notes that review and reassessment of the interpretations in light of the participants viewpoint differentiates a qualitative study from a journalistic interview. "...One of the most characteristic things about good research ... is that it goes back to the subjects with the tentative results, and refines them in the light of the subjects' reactions" (Reason, 1981, p.248).

All the participants in this study were given a copy of the initial analysis of the data, and all agreed with the portrayal of the data by the researcher. Additionally, the participants received the final analysis, and were polled for their comments. The responses to the model developed in this research were enthusiastic. Participants felt that their own understanding of their experience of anticipation of death of self was deepened.

The validity of qualitative research is supported by using a verbatim transcription of the data (Patton, 1990). Any summary which might be done by the transcriber would necessarily change the meaning of what the participants said and would constitute an interactive effect by the researcher. On the question of the generalizability to others, phenomenological inquiry assumes that the findings are trustworthy only if they are limited to the participants in the study at the point in time that they were interviewed for the research, unless demonstrated otherwise (Reason, 1981). Unlike a quantitative study in which the transferability of the findings must be demonstrated by the controls the investigators put on their sampling, the qualitative investigator is under an obligation to provide sufficient descriptive evidence so that others may make judgements about the applicability of the findings to different people in different settings, and with different histories and contexts (Lincoln & Guba, 1985). This approach has been taken in this research, with thick description in Chapter One, augmented by further data presented as 'Additional Supportive Quotations'.

The qualitative comparative to the quantitative concept of reliability is dependability (Lincoln & Guba, 1985). Whereas the criteria for reliability in the quantitative approach indicate the extent to which different investigators will have the same results using the same methods with a similar sample, dependability in the qualitative approach is used to evaluate the rigor with which the investigator has used self as an instrument. The clarity with which the researcher presents preconceptions and prior understandings, and the description of the bracketing process, will indicate whether the resulting constructs are a product of careful thoughtfulness and "rigorous interrogation of the phenomenon" (Van Manen, 1990, p. 131). The declaration of self in front of the text is used to manufacture distance so investigators "can bring themselves to see with new detachment the categories and assumptions that organize their worlds" (McCracken, 1988, p.23). Effort to promote dependability through declaration of self in front of the text has been presented in the preceding section of this chapter.

In qualitative inquiry, the concept of objectivity, which in quantitative inquiry addresses the position of the investigator and the design of the study, is replaced by the concept of confirmability (Lincoln & Guba, 1985). Confirmability of the data indicates the extent to which the findings are grounded in the data, and can therefore be illustrated by examples from the data. Mechanical recording of the interviews supports the confirmability of the data as being true to the expression of the participant. The scientific language reductions which are used in explaining the results should be true to the original data, and be confirmable by reference to the data (using quotes as illustrations). Additionally, a main criterion for confirmability is whether the results illuminate understanding of the phenomenon for others, including the participants. Reason (1981) terms this as 'perspective', which is personal knowing from a distance, and does not imply the universality of objectivity, nor the subjectivity of personal bias. Van Manen's (1990) conception of the transparency of a phenomenological description, and Spiegelberg's (1975) terms 'clearness' and 'visibility' are also illustrative of the nature of confirmability in phenomenological constructs. The reader of the findings ultimately determines confirmability.

8. Summary

In this chapter the methodology of phenomenology, and the methods used in this study for sampling, data collection, analysis, interpretation, and of ensuring the validity of the data, as well as the means by which the human subjects involved were protected, have been outlined. In addition, the researcher has bracketed her own experience and assumptions which were held before beginning the study.

Return to Table of Contents
CHAPTER FIVE: DISCUSSION

The findings of this phenomenological study portray the anticipation of death in healthy later life as a complex, multifaceted and dynamic phenomenon. The healthy older people who participated in this study described the anticipation of death of self in later life as an on-going process of creating readiness and achieving purpose in life while facing their future death. Participants both reflected and projected their thoughts and activities in five spheres of being: internal being; existence in the world as a solitary being; relationships with other individuals; existence in the world as part of humankind; and existence after death.

In the following sections, the findings of this research are discussed. Findings are linked with knowledge in the literature of the disciplines of nursing, psychology, and philosophy. The implications for nursing education and practice, and questions arising for future research are delineated.

1. Relation of the Findings to Previous Literature on the Anticipation of Death in Healthy Later Life

Prior to this study, the literature on anticipation of death of self was dominated by studies which isolated one or two dimensions to attempt to describe this experience. In the past, the emotion of fear has been strongly emphasized in the literature. Although the participants in this study talked about fear, it was not their predominant concern. Rather, the reflections and projections which comprise the process of experiencing being and anticipating death in later life reveal a dynamic process of anticipating death of self, of which fear is a limited component.

When the participants in this research spoke about fear, their stories focussed narrowly on the fear of actually dying, with the possibility of prolonged suffering being the subject of most concern. Anticipation of the outcome of death was not described as being approached with fear, but with some unease, or curiosity, or an acceptance that there would be something surprising about life after death.

The literature prior to this study also connected thoughtfulness about death to psychological dysfunction. The studies cited by Rhudick and Dibner (1961), Templar (1971), and Cataldo (1989) were representative of an underlying assumption that death concern was somehow related to mental instability. The obvious implication here was that death concern, or thoughtfulness, was symptomatic of dysfunction, rather than thoughtfulness about the human experience of death. By contrast, the findings of this study revealed the process of anticipation of death as a constructive experience of human growth and development through creating readiness for death while achieving purpose in life. Mental illness is not a universal human experience, however, death is universal and inevitable. Thus, it is important to dispel the notion of the association of psychological dysfunction and thoughtfulness about death.

In Canada's multicultural society, holding the view that death concern is associated with mental instability may lead nurses to misunderstand patients outside the Judeo-Christian religious sphere. For example, followers of Confucianism are taught to live in harmony with the whole process in which humankind finds itself, including death (Smart, 1968). Buddhists are taught to continuously strive for deeper serenity and insight, to meditate on death, and not to make plans that do not reckon with the inevitability of death as it is unrealistic to live with the assumption that joys can be lasting (Smart, 1968).

The phenomenological interpretation of the experience of the participants in this research has demonstrated that anticipation of death of self in healthy later life can be a dynamic, continuing process. The findings of this study may help older persons and their caregivers alike to approach this topic in a manner which will be helpful and facilitative of achieving human growth through the experience of anticipating death in healthy later life.

The findings in this study are consistent with philosophical literature on the nature of being. In a philosophical phenomenological inquiry (self as the only participant) into the event of death, Leman-Stefanovic (1987) discussed the Heideggerian notion that being authentic to oneself requires defining "being-in-the-world" as "being-towards-death". In other words, authenticity does not come from thinking of oneself as an entity that eventually must die; rather, authenticity comes from one's entire understanding that the world is shaped by the temporality of one's existence. The anticipation of death of self in healthy later life, as discussed in the findings for this research, was an on-going process of creating readiness and achieving one's life purpose through five spheres of being which constituted the time and space of one's existence.

In addition to authenticity, the theme of achieving purpose presented in these findings is in congruity with another Heideggerian notion. Leman-Stefanovic (1987) discussed the phenomenon of "care", which she stated was defined by Heidegger as the "ahead-of-itself". This notion of "care" was presented as something that is essential to the basic human constitution, as always encompassing "something-more" to accomplish, and as something always outstanding. Reflecting on the notion of acceptance of death, Leman-Stefanovic (1987) extended the description of the need to accomplish for a hypothetical person:

He may wish to ensure that those whom he leaves behind are well taken care of; he may wish to find religious peace through a minister; he may wish to be assured that he is not dying in vain, that his being has some continuity through his work, his children, his friends. Perhaps one may never really ever be finished with these things completely, but if one is able to achieve a sense that people and things which are important to him will carry on sufficiently well without him, that will bring a great sense of repose and a peace of soul, preparatory to this final phase of "acceptance".(p. 188)

The sudden fleeting or flashing thoughts of their future non-existence described by some of the participants in this study are consistent with such fleeting reflections described by Leman-Stefanovic (1987). Descibing the repeated re-living of the sudden emotional impact of facing her own death after a near auto accident, Leman-Stefanovic stated that she had

"a sense of being suspended in a vacuum ... whereby all my familiar points of spatio-temporal orientation disappear[ed]" (p. 170).

Leman-Stefanovic (1987) described the moment of shock as being "more than a mental state"(p.171):

The moment of shock, the sense of "suspended animation" within a void, is a state of being "in-between" the "ever-more" and the "never-more"; one hangs suspended alone in a state of being "in-between" one's previous perception of life as stretching into a never-ending future, and a realization of the full meaning of one's finitude. In a sense, time "stops", that is, it is fully concentrated in the moment of truth wherein one's life as one knows it, is completely and totally to be re-oriented around a determinate e-vent [sic] which, while not empirically here, fully captures my imagination and my total way of being-in-the-world. (p. 171)

2. Implications for Nursing Education

To date, the anticipation of death of self in later life has received very little attention in nursing gerontological textbooks. In Beckingham and Dugas (1993), discussion of this topic was missing entirely. McFarland and McFarlane (1989) incorporated anticipation of death of self in later life as a factor that may be related to anticipatory grieving. Another text briefly noted that anticipation of death of self in healthy later life may contribute to anxiety (Carpenito, 1989). Miller (1990) briefly listed this topic as one of the losses in life events and adjustments in later life.

Nursing educators must come to terms with the fact that for an older client, sudden death is possible at any time. Being a healthy older person is tantamount to living with a terminal diagnosis; that is, death is inevitable, and can reasonably be expected to take place within a limited time frame in an unpredictable fashion. Designers of nursing education have hitherto placed the emphasis on assisting younger people to cope with untimely death and dying. Failing to include the experience of death in later life, quite possibly has inhibited nurses' understanding of anticipation of death in older persons.

Gerontological nursing is complex. The combination of multiple chronic illnesses, acute illness, potential interaction of many medications and increased frailty, which may present together in geriatric clients is a challenge to any nurse who is planning care. These many complex details have the potential to distract the nurse from a holistic view of the client. Holistic patient-centred care includes evaluation of the illness experience of clients, including their suffering and the personal meaning of the illness for them (McWhinney, 1995). The content of courses in gerontological nursing needs to be framed within the context of the experience of the geriatric client as being at the end of life. Recognition that older people are anticipating their death, and may be experiencing fear, needs to be a basic premise of caregiving to this client population.

This research illustrates that many older people may be creating readiness and achieving purpose by reflecting on death in their spheres of being, and projecting thoughts and actions into those spheres of being. They may be at various levels of readiness in their spheres of being and at various levels of fulfillment in their sense of purpose. Additionally, reflections or projections, of their own future death by older persons may be made in a fleeting manner.

Some of the participants in this research incorporated the advent of disabilities, losses and the potential development of dependence into their concept of their overall death process, as if those changes were components of their death in its entirety. It is possible that what nurse educators teach as the losses of aging, should, if the viewpoint of these older persons is representative, be taught as the process of dying.

Above all, the findings of this study clarify the importance of including anticipation of death of self in any course curriculum for gerontological nursing. Nurses working in most health care settings care for increasing numbers of older clients as the proportion of older people in the population increases. Nursing students need to be taught to listen for older persons' readiness for death, efforts at creating readiness and achieving sense of purpose and reflections or projections on their own death when giving care. Nurses also should learn how to feel comfortable in validating the older person's point of view and to use themselves therapeutically if the older person finds it helpful to discuss their thoughts about their own future death.

3. Implications for Nursing Practice

There are several implications of this research for nursing practice. Older clients may be going through a process of anticipating death of self such as that described by participants in this study. Secondly, the fear of the dying process, and concern about a future lack of control over their dying process, merits attentive consideration by practitioners of nursing when planning care for older adults.

While the death rate at the beginning of this century was high in infancy, and spread across the age spectrum, now death is largely reserved for those who are old (Brown, 1990). Generally, older people die of chronic diseases that lengthen the dying process and, for them, the prospect of suffering through dying is much worse than the prospect of death itself (Brown, 1990). Yet our health care system is largely based on the bioscientific medical model of aging, the logical extension of which is that disease, rather than aging, causes death. This leads quickly to the belief that every known life-saving technology should be used to keep people alive (Brown, 1990). In the atmosphere created by this bioscientific medical model, the environment of the dying trajectory for older persons is being controlled by nurses and physicians, who generally have inadequate training in gerontology and thanatology (Brown, 1990). The nursing profession could be developing a more effective dialogue with its older clientelle, in order to ascertain whether, in fact, care, or harm, is being delivered to older adults through nursing practice.

The bioscientific medically-oriented model holds practitioners to the ultimate aim of "curing". The inevitability of death in old age precludes this aim. Thus, practitioners caught up in this model are ill-prepared to provide effective health care to older adults. The nursing profession must therefore look outside this model for guidance to its health-oriented practice. The reframing of the changes in later life from the losses of aging to the process of dying, may have the potential to fundamentally change the approach of nurses to care of older adults.

The objectives of nursing care for older persons include the alleviation of pain and suffering related to death. These objectives could also include active presence with and assistance to older persons as they work through the dynamic process of anticipation of death of self. In light of these objectives, the new understanding of how fear enters into anticipation of death of self, as described in this research, illuminates strategies for theorists and caregivers in pursuit of these objectives. The unease, curiosity, or acceptance associated with the outcome of death cannot be altered. However, the nursing intervention of providing a comforting, accepting presence which permits older adults to articulate this experience may provide substantial and meaningful emotional support. Concrete and specific recognition of the linkage of the fear older adults experience to anticipation of suffering during the dying process can afford opportunities for health professionals to identify and introduce appropriate solutions to older persons' fear of pain, dependence, uselessness and causing hardship to their whole family. Additionally, open exploration, elucidation and separation of fears of dying from more general unease or curiosity about life after death, may facilitate older persons' integration of reflections and resulting projections during their dynamic process of anticipation of death. Above all, using this knowledge of how fear is and is not a component of anticipation of death of self may help caregivers to avoid worsening the physical and mental suffering of older adults that comes from caregivers' acting with a lack of understanding of the process of anticipation of death.

At present, the predominant view of older adults in the fields of health and social services, is that the old are helpless, dependent and in need of social services (Brown, 1990). Such a view is consistent with the control of the health care delivered to older people remaining in the hands of the health care professionals, including nurses. This approach does not demand solicitation of the views of the older clients of the system. An example of the assumption of helplessness and dependence as characterizing older people, and of the presumption of the need to be in control by the nursing profession can be seen in the following journal article excerpt:

As individuals progress through the last phase of life, nurses are called on to identify psychosocial needs, create a growth-promoting environment, provide education and give emotional support. (Brokopp, King, & Hamilton, 1991, p. 245-246)

However if older people are viewed as autonomous and capable of enacting their free will, rather than helpless and dependent, then older people will be able to exert more control over the health care they receive. The older clients themselves should establish the priorities of care planning by the identification of their own personal, psychosocial, and other needs. In such an environment, the fear of the dying process, as described by the participants in this study, may decrease, since older people could be assured of maintaining control over their own dying process.

For nursing practice, the implication of the possibility that their older clients may be going through an active developmental process of anticipating death of self, is that it is important for nurses to be mindful of this possibility in their interaction with older people. Nurses could be open to playing a role in the reflecting and projecting in which older clients may be engaged in the process of anticipating their death. This could be done by entering into meaningful conversations when older people desire them, and by allowing older people to express what they are feeling at the moment of their interaction with the nurse. Not to validate the humanity of fellow beings by listening and conversing with them is to treat them as being less than human (Brown, 1990).

Robert Kastenbaum addressed the issue of younger people feeling uncomfortable discussing death with older people in a 1977 essay entitled "Death and Development Through the Lifespan":

Old people have many practical reasons to think about death. This sometimes is not appreciated by the younger people in their lives (including middle-aged children) who react as though any talk about death is "morbid" and distasteful. The old person may be concerned about the best way to distribute personal possessions to the survivors, about arranging for the type of funeral and burial or cremation that suits his or her value system, and about "saying goodbye" in a way that strengthens long affections and heals or resolves old hurts. Younger people sometimes are apprehensive that once an old person starts talking about death, there will be no stopping him or her. This is not usually the case. Death is a realistic concern of the old person, and he or she has a need to share in his or her thoughts and feelings on the topic. After the opportunity to speak his or her mind and to entertain a relevant response, the old person is likely to go on to other topics, returning from time to time to death when there is something further to be said. Obsession with death is more likely to develop when there is nobody around who is willing to listen attentively to even a little "death talk".(Kastenbaum,1977, p.42)

Older people may reflect on their past and present and project themselves into the future, integrating their experience while creating readiness for death and achieving purpose in life in anticipation of death. The stories that older people tell may, at times, feel like a waste of a busy nurse's time. However, if the nurse frames this talkativeness as a need for relevant conversation in the older person's process of anticipating death of self, the nurse more likely will be able to hear what the older person has to say. A comment like, "What made you think of that story today?" may help an older person ventilate thoughts. Also, if older people feel that a nurse is respectful and interested, because the nurse has listened to some thoughts, they may feel that there is enough trust in the relationship to share a deeper concern.

Nurses could also be in a position to teach significant others about the possible reasons behind the older person's desire to discuss certain topics. This intervention could help the family and others concerned with the welfare of the older person to develop skills for effective and mutually satisfying interaction with their loved one.

4. Implications for Future Research

Although death is universal, it is not ordinary. Thus, death can be expected to be a topic which people in later life deal with using great energy. The nature of the process of anticipation of death will vary with individuals. The approach which individuals take may reflect a continuum, which ranges between extreme thoughtfulness and absolute avoidance. Several participants in this study stressed the unusualness of being able to have a frank and open discussion about their own future death, mentioning that most of their peers were unable to do so. Clearly, there needs to be further research into the development of adult constructs or conceptual structures and processes of anticipation of death of self as suggested by Kastenbaum (1992). An additional implication of the avoidance of this topic by many of their peers reported by the participants, is the difficulty which such "avoiders" might have when approached to complete advance directives. Researching the best approach to this difficult task should have high priority if their use is widespread or becomes mandated.

Deeper understanding of the process of anticipation of death of self in healthy later life is needed. The participants in this study were in the early years of later life (65-69), all were Christian, all had descendants, and all were living in comfortable circumstances. Phenomenological research with participants who are anticipating death of self from the perspective of older ages, non-Christian religions, and varying family and social circumstances, would further broaden the range of human experience from which our understanding of anticipation of death of self in healthy later life is gleaned.

The findings of this study raise many questions for future research. Some of these questions could be: How do older people experience growth and development of self in later life? What is the nature of the fear of the dying process in later life? How do older people experience dying itself? What meaning does completion of advanced directives have for older people? What is the nature of creating readiness for death? What is the nature of achieving purpose before death? What is the nature of fleeting reflection and projection of future death of self? What is the nature of the response of younger family members to the anticipation of death by their older relative? What is the nature of unfinished business which may prevent creating readiness and achieving purpose in anticipation of death? Does the education of nurses about anticipation of death of self in healthy later life affect their clients' perception of care received? Such research and its implementation in practice would facilitate the development of gerontological nursing practice in this country.

5. Conclusion

The findings of this research represent a beginning to answering the questions posed by earlier gerontological researchers. Kastenbaum (1992) suggested that research be done to discover the nature of the experience of older people who are thinking about death without an obvious threat to their existence. Marshall (1975) stressed the importance of being able to assess the impact, on everyday lives, of the recognition of finitude in older persons (Marshall, 1975).

This study was undertaken to discover how healthy older persons experience the anticipation of death of self. A client-centred focus for nursing demands attending to the process of anticipating death of self which individual older people are experiencing. The phenomenological approach to this question has permitted the development of a deeper understanding and insight into the experience of anticipation of death of self of these older participants.

Return to Table of Contents
APPENDIX A: LETTER OF INFORMATION

THE EXPERIENCE OF ANTICIPATING DEATH OF SELF IN HEALTHY LATER LIFE:

Researcher: Jennifer Ghent-Fuller

As a person over the age of sixty-five, able to communicate well in English, and having indicated that you are willing to consider being interviewed on the topic of the experience of anticipating death of self in healthy later life, you are being asked to take part in this nursing research study.

As part of the study, you will be interviewed in your home by the researcher at a time convenient to you. The interview will be recorded on audiotape. The approximate length of time for the interview will be 1 hour. The interview may be shorter or longer, depending on how long you wish to discuss this topic. The interview will take place with only the researcher and yourself present in the room, in order that we may completely concentrate on the research topic and on your thoughts in private. You may ask to stop the interview or to have the tape recorder turned off at any point during the interview. The tapes of the interview will be kept locked in the researcher's home until the study is completed, at which time they will be destroyed.

The information that you give to the researcher will be treated with strict confidentiality. If the results of the study are published or shared in any way with others, your name will not be revealed. The tapes of the interview will be transcribed word for word, without any information which could disclose your identity.

During the interview, you will be asked some basic questions which will describe yourself and your family situation. You will also be asked to describe what things you think of, or feel, when you look ahead to your own death. You will be asked to describe each type of thought or feeling as fully as you are able and willing to do. Participation in the study is voluntary. Should you wish to stop the interview or withdraw from the research, you are free to do so at any time.

After the completion of the interview, the researcher will analyze the thoughts and feelings that you and other participants have on this topic to identify how healthy older people experience facing the thought of their own death. The researcher will ask if you would give permission to be contacted should any clarification of your thoughts and feelings be needed during the analysis, and again, to review the analysis at the end of the study.

Should you have any questions, please feel free to contact the researcher at 578-3154, or the Faculty Advisor, Dr. Carol McWilliam, at (519) 661-3802.

Yours sincerely,

Jennifer Ghent-Fuller
APPENDIX B: LETTER OF INTRODUCTION

September 1995

My name is Jennifer Ghent-Fuller, and I am conducting a nursing research project as a student in the Master's of Science in Nursing program at the University of Western Ontario, under the supervision of my faculty advisor, Carol McWilliam, Ed.D. of the Departments of Nursing and of Family Medicine.

In the course of my nursing work, I have found that there is a need for nurses to better understand the experience of people who are 65 years of age and older in regard to their thoughts and feelings about their own natural death as an older person. This understanding would help nurses to respond more appropriately and skillfully to older patients' needs.

In order to assist in the development of such an understanding, I have designed a research thesis entitled "The experience of anticipating death of self in healthy later life". The research was approved by the Review Board for Health Sciences Research Involving Human Subjects at the University of Western Ontario. The method of research involves interviews with people aged 65 and over. Further details about the interview are included in the attached Letter of Information.

You have received this letter to request your participation in this research as per the Letter of Information. The interviews will be conducted between now and the middle of October, 1995. Enclosed is a stamped, self-addressed envelope. Please return the attached form indicating your wishes at your earliest convenience. If you are willing to participate, please fill in details about how I can arrange a time for an interview.

Many thanks for considering this request.

Sincerely,

Jennifer Ghent-Fuller
APPENDIX C: NOTICE OF PARTICIPATION DECISION

Name: (Please print) ______________________________________

I will participate ? Yes ? No

If "Yes", please fill in:

Phone number:_______________________

When I can be reached: Date(s)________________________

Time(s)____________________________
APPENDIX D: GENERAL INTERVIEW GUIDE

General Interview Guide for The Experience of Anticipating Death of Self in Healthy Old Age

1.Now that we have begun, please tell me about yourself. Probe questions to elicit values, needs, critical incidents which have meaning.

2.What do life and death mean to you, in general terms first of all? Probe - What do life and death mean to you personally?

3. What things do you think of, or feel, when you look ahead to your own death? Probing for elaboration when necessary (eg. you said ___, please tell me a little more about that...) Probe- what other things do you think of or feel when you think of your own death?

4. How often do you think of your own death? Probe - are there any special circumstances that bring thought of your future death into your mind?

5. What helps you to face your own death? Probing for elaboration when necessary \- who, what, how, feelings, experiences

6. What things hinder your facing your own death" Probing for elaboration when necessary - who, what, how, feelings, experiences

7. How do you deal with thoughts of your own death? Probing for elaboration when necessary - who, what, how, feelings, experiences

8. In what way do/could others hinder you in facing your own death? Probing for elaboration when necessary - who, what, how, feelings, experiences

9. In what way do/could others help you in facing your own death? Probing for elaboration when necessary - who, what, how, feelings, experiences

10. Is there anything else you would like to tell me about how it feels to look ahead to your own death?

11. How has participating in this interview affected you?
APPENDIX E: PERSONAL HISTORY SHEET

I would like to get a brief outline of your personal life and family structure in order to evaluate the significance of your social circumstances in the analysis:

Name-

Age-

Born in Canada?-

Or # of years lived in Canada-

Please describe your education to me-

Retired or working? -

Type of work -

If retired, what are your favourite activities? -

Are you involved with any groups or organizations? -

To what extent is religion a part of your life? -

Religion -

Activity within religion? -

Please briefly describe your family to me -

Family of origin -

Where? -

Family now -

Grandchildren? -

Who is at home with you now? -

Are you caring for anyone on a regular basis who is not living with you? -

How would you describe your health in general terms?
APPENDIX F: CERTIFICATION OF APPROVAL OF HUMAN RESEARCH

APPENDIX G: CERTIFICATE OF EXAMINATION

Return to Table of Contents

REFERENCES

Axelrod, C. D. (1986-87). Reflections on the fear of death. OMEGA, 17, 51-64.

Bailly, D. J., & DePoy, E. (1995). Older peoples' responses to education about advance directives. Health and Social Work, 20(3), 223-228.

Baum, S. K., & Boxley, R. L. (1984). Age denial: Death denial in the elderly. Death Education, 8(5/6), 419-423.

Bascue, L. O., & Lawrence, R. E. (1977). A study of subjective time and death anxiety in the elderly. OMEGA, 8(1), 81-90.

Beckingham, A. C. & DuGas, B. W. (1993). Promoting healthy aging: A nursing and community perspective. Toronto: Mosby - Year Book.

Bengston, V. L., Cuellar, J. B. , & Ragan, P. K. (1977). Stratum contrasts and similarities in attitudes toward death. Journal of Gerontology, 32(1), 76-88.

Benner, P. (1994). The tradition and skill of interpretive phenomenology in studying health, illness, and caring practices. In P. Benner (Ed.), Interpretive phenomenology: Embodiment, caring, and ethics in health and illness (pp. 99-127). Thousand Oaks, CA, USA: Sage Publications.

Bermann, S., & Richardson, V. (1986-87). Social change in the salience of death among adults in America: A projective assessment. Omega, 17(3), 195-207.

Butler, R. N. (1974). Successful aging and the role of the life review. Journal of the American Geriatrics Society, 12(12), 529-535.

Carpenito, L. J. (1989). Nursing diagnosis: Application to clinical practice. Philadelphia: J.B.Lippincott Co.

Cataldo, J. K. (1989). An investigation of the relationship of hardiness and death attitudes to depression in older persons in skilled nursing facilities. (Doctoral dissertation, New York University). Dissertation Abstracts International, Accession Number 1991127870.

Chronic Care Implementation Task Force (1995). Report of the Chronic Care Implementation Task Force. Hamilton, Ontario: Educational Centre for Aging and Health.

Dickinson, G. E., Sumner, E. D., & Frederick, L. M. (1992). Death education in selected health professions. Death Studies, 16, 281-289.

Durlak, J. A. (1973). Relationship between attitudes toward life and death among elderly women. Developmental Psychology, 8(1), 146.

Erikson, E. (1963). Childhood and Society. New York: W. W.Norton & Co.

Erikson, E., Erikson, J. M., & Kivnick, H. (1986). Vital involvement in old age. New York: W.W. Norton & Company.

Feifel, H. (1956). Older persons look at death. Geriatrics, 11(3), 127-130.

Feifel, H. (1969). Death - relevant variable in psychology. In R. May (Ed.) Existential psychology (pp. 58-71). New York: Random House.

Franke, K.J., & Durlak, J.A. (1990). Impact of life factors upon attitudes toward death. OMEGA, 21, 41-49.

Fry, P. S. (1990). A factor analytic investigation of home-bound elderly individuals' concerns about death and dying, and their coping responses. Journal of Clinical Psychology, 46(6), 737-748.

Gesser, G., Wong, P. T. P., & Reker, G. T. (1987 - 1988). Death attitudes across the life-span: The development and validation of the Death Attitude Profile (DAP). OMEGA, 18, 113-128.

Gilliland, J. C. & Templer, D. I. (1985-86). Relationship of death anxiety scale factors to subjective states. OMEGA, 16, 155-167.

Gioiella, E. C. (1986). Gerontological content for basic professional nursing preparation. In E.C. Gioiella (Ed.), Gerontology in the professional nursing curriculum. New York: NLN # 15-2151.

Gullickson, C. (1993). My death nearing its future: A Heideggerian hermeneutical analysis of the lived experience of persons with chronic illness. Journal of Advanced Nursing, 18, 1386-1392.

Hammond, M.A., Howarth, J.M. & Keat, R.N. (1991).Understanding phenomenology. Cambridge, Mass.: Basil Blackwell, Ltd.

Heron, J. (1981). Experiential research methodology. In P. Reason and J. Rowan (Eds.), Human Inquiry (pp. 153-171). Great Britain: John Wiley & Sons, Ltd.

Jeffers, F. C., Nichols, C. R., & Eisdorfer, C. (1961). Attitudes of older persons toward death: A preliminary study. Journal of Gerontology, 16(1), 53-56.

Jones, S. A. (1993). Personal unity in dying: Alternative conceptions of the meaning of health. Journal of Advanced Nursing, 18, 19-24.

Kalish, R. A. & Reynolds, D. K. (1981). Death and ethnicity: A psychocultural study. Farmingdale, New York: Baywood Publishing Company, Inc.

Kastenbaum, R. (1987-88). Theory, research and application: some critical issues for thanatology. OMEGA, 18, 397-410.

Kastenbaum, R. (1992). The Psychology of Death. New York:Springer Publishing Co.

Koenig, H.G. (1988). Religious behaviours and death anxiety in later life. The Hospice Journal, 4(1), 3-24.

Kurlychek, R. T., & Trepper, T. S. (1982). Accuracy of perception of attitude: An intergenerational investigation. Perceptual and Motor Skills, 54, 271-274.

Lavigne-Pley, C., & Lévesque, L. (1992). Reactions of the institutionalized elderly upon learning of the death of a peer. Death Studies, 16, 451-461.

Le compte, M. D. & Goetz, J. P. (1982). Problems of reliability and validity in ethnographic research. Review of Educational Research, 52(1), 31-60.

Leininger, M. (1985). Nature, rationale, and importance of qualitative research methods in nursing. In M. M. Leininger (Ed.), Qualitative Research Methods in Nursing (pp. 1-25). New York: Grune & Stratton, Inc.

Leman-Stefanovic, I. (1987). The Event of Death. Dordrecht, The Netherlands: Martinus Nijhoff Publishers.

Leonard, V. W. (1994). A Heideggerian phenomenological perspective on the concept of person. In P. Benner (Ed.), Interpretive phenomenology: Embodiment, caring, and ethics in health and illness (p.99-127). Thousand Oaks, CA, USA: Sage Publications.

Lester, D. & Templer, D. (1992-93). Death anxiety scales: a dialogue. Omega, 26(4), 239-253.

Lincoln, Y.S. and Guba, E.G. (1985). Naturalistic Inquiry. Beverly Hills: Sage Publications.

Lynch-Sauer, J. (1985). Using a phenomenological research method to study nursing phenomena. In M. M. Leininger (Ed.), Qualitative Research Methods in Nursing (pp.93-105). New York: Grune & Stratton, Inc.

Marks, A. (1986). Race and sex differences and fear of dying: A test of two hypotheses - high risk or social loss? OMEGA, 17, 229-237.

Marshall, V. W. (1975). Age and awareness of finitude in developmental psychology. Omega, 6(2), 113-129.

Marshall, V.W. (Ed.)(1986). Later life: The social psychology of aging. Beverly Hills: Sage Publications.

Marshall, V. W. (1987). Aging in Canada: Social perspectives (2nd Ed.). Markham, ON: Fitzhenry and Whiteside.

McCracken, G.D. (1988). The Long Interview. Beverly Hills, CA: Sage Publications.

McFarland, G.K. & McFarlane, E.A. (1989). Nursing diagnosis and intervention: planning for patient care. Toronto: C.V. Mosby Year Book.

McWhinney, I.R. (1995). Why we need a new clinical method. In M. Stewart, J. B. Brown, W. W. Weston, I. R. McWhinney, C. L. McWilliam, & T. R. Freeman (Eds.), Patient-centered medicine: Transforming the clinical method (pp. 1-20). Thousand Oaks, CA: Sage Publications.

Miller, C.A. (1990). Nursing care of older adults. Glenview, Illinois: Scott, Foresman/Little, Brown Higher Education.

Mitchell, G.J. (1990). The lived experience of taking life day-by-day in later life: research guided by Parse's emergent method. Nursing Science Quarterly, 3(1), 29-36.

Molloy, D. W. & Guyatt, G. H. (1991). A comprehensive health care directive in a home for the aged. Canadian Medical Association Journal, 145(4), 307-311.

Morse, J. (Ed.) (1991). Qualitative nursing research: a contemporary dialogue (Rev. ed.). Newbury Park, CA: Sage Publications.

Mullins, L. C., & Lopez, M. A. (1982). Death anxiety among nursing home residents: a comparison of the young-old and the old-old. Death Education, 6, 75-86.

Nehrke, M. F., Bellucci, G., & Gabriel, S. J. (1977-1978). Death anxiety, locus of control, and life satisfaction in the elderly: toward a definition of ego-integrity. Omega, 8(4), 359-368.

Oiler, C. (1982). The phenomenological approach in nursing research. Nursing Research, 31(3),178-181.

Omery, A. (1983). Phenomenology: a method for nursing research. Advances in Nursing Science, 5(2), 49-63.

Patton, M. Q. (1990). Qualitative evaluation and research methods (2nd Ed.). Newbury Park, CA: Sage Publications.

Rappaport, H., Fossler, R. J., Bross, L. S., & Gilden, D. (1993). Future time, death anxiety, and life purpose among older adults. Death Studies, 17, 369-379.

Reason, P. (1981). Issues of validity in new paradigm research. In P. Reason and J. Rowan (Eds.), Human Inquiry (pp. 239-250). Great Britain: John Wiley & Sons Ltd.

Rhudick, P. J. & Dibner, A. S. (1961). Age, personality and health correlates of death concerns in normal aged individuals. The Journal of Gerontology, 16, 44-49.

Ross, L. M., & Pollio, H. R. (1991). Metaphors of death: a thematic analysis of personal meanings. OMEGA, 23, 291-307.

Sanders, J. F., Poole, T. E., & Rivero, W. T. (1980). Death anxiety among the elderly. Psychological Reports, 46, 53-54.

Schorr, J. A. & Schroeder, C. A. (1989). Consciousness as a dissipative structure: An extension of the Newman model. Nursing Science Quarterly, 2(4), 183-193.

Smart, N. (1968). Attitudes towards death in eastern religions. In A. Toynbee, A. K. Mant, N. Smart, J. Hinton, S. Yudkin, E. Rhode, R. Heywood, H. H. Price (Eds.), Man's concern with death (pp. 95-115). San Francisco: McGraw-Hill Book Company.

Spiegelberg, H. (1970). On some human uses of phenomenology. In F.J. Smith (Ed.), Phenomenology in Perspective (pp. 16-31). The Hague: Martinus Nijhoff.

Spiegelberg, H. (1975). Doing phenomenology: Essays on and in phenomenology. The Hague: Martinus Nijhoff.

Stephens, R. L., Baab, A. K., & Castleman, T. A. (1991). Cancer patient perception of the living will: report of a pilot survey. Omega, 23(3), 181-189.

Storch, J. L., & Dossetor, J. (1994). Public attitudes towards end-of-life treatment decisions: Implications for nurse clinicians and nursing administrators. Canadian Journal of Nursing Administration, 7(3), 65-89.

Stricherz, M., & Cunnington, L. (1981-1982). Death concerns of students, employed persons and retired persons. OMEGA, 12, 373-379.

Swenson, W. M. (1961). Attitudes toward death in an aged population. Journal of Gerontology, 16(1), 49-56.

Templer, D. I. (1970). The construction and validation of a death anxiety scale. The Journal of General Psychology, 82, 165-177.

Templer, D. I. (1971). Death anxiety as related to depression and health of retired persons. Journal of Gerontology, 26, 521-523.

Thorson, J. A., & Powell, F. C. (1992). A revised death anxiety scale. Death Studies, 16, 507-521.

Tomer, A. (1992). Death anxiety in adult life - theoretical perspectives. Death Studies, 16, 475-506.

Van Manen, M. (1990). Researching Lived Experience. London, ON: The Althouse Press.

Warren, W.G. (1989). Death education and research: Critical perspectives. New York: The Haworth Press.
DEDICATION

This thesis is dedicated to the memory of my mother, Margaret, whose sudden death during this research increased the poignancy of its meaning to me. It is also dedicated to my father, Arthur, my step-father, Keith, and to my mother's sister, Gena and her husband, Jack. Their weekly phone conversations and loving encouragement from afar gave me heart and purpose. Lastly, it is dedicated to my dear husband, David, and to my children, Sandra and Daniel, whose kindness, forbearance, and love, were my foundation.

ACKNOWLEDGEMENTS

I would like to thank my advisor, Carol L. McWilliam, Ed.D., for her wisdom, thoughtfulness and patience, and for being a wonderful teacher. I would also like to thank my committee members, Elsie MacMaster, M.Sc.N., and Michael J. Stones, Ph.D. for their willingness to support this effort. Additionally, I would like to extend my thanks to Carroll Iwasiw, Ph.D., Coordinator of the Graduate Program, for her support. Finally, my thanks are extended to the anonymous eight participants who donated their thoughts and time to help me create this work.

ABOUT THE AUTHOR:

Jennifer Ghent-Fuller was born in Ontario, Canada in 1951. She holds a BA (Queen's University, Kingston, ON - 1973), a BScN (The University of British Columbia, Vancouver, BC - 1979), and an MScN (The University of Western Ontario, London, ON - 1996). In her capacity as a nurse, she has worked as a staff nurse, discharge planner, clinical nurse specialist (geriatrics), clinical manager (dementia unit), and, after the initial publication of this thesis, as an educator and counsellor for people with dementia, and family members and others caring for a person with dementia. She has also served as a literacy volunteer and a volunteer educator on the topic of elder abuse. She has published two books on the topic of dementia, 'Thoughtful Dementia Care: Understanding the Dementia Experience' (2012), and 'It Isn't Common Sense: Interacting with People who have Memory Loss Due to Dementia.'(2013). The book, Thoughtful Dementia Care, is an expansion of the paper 'Understanding the Dementia Experience', which remains available at no charge online at your favourite retailer. Jennifer Ghent-Fuller is now retired.

Return to Table of Contents
