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

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

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

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

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

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

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

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

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

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

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

S.M. GOrman The first anniversary 'yahrzeit' is marked by the family Rinpoche(1995) was shocked by the contrast of lack of gathering at the cemetery to reflect on the life of the positive rituals in the West to those which attest to the deceased. It is usual at this time to dedicate the tombstone majestic vision of life and death underlying Tibetan tra and Sweeting and Gilhooley(1992) describe this as the dition. Toolis(1995)acknowledges the negative effects of third phase in the death ritual, signifying that the deceased the hushed reverence and deep embarrassment normally is now regarded as a dead ancestor. Helman (1985)sees associated with the Anglo-Saxon rituals surrounding this as the last of a series of funerals during which the death. Cytron(1993)condemns the fast grief of modern diseased gradually leaves the land of the living American Jews and speculates that this is due to secularize There are many similarities between Jewish rituals and ation and medicalization of terminal care her communities such as rural Ireland (Keane Illich(1990) demonstrated the medicalization of death 1985, Taylor 1988, Lillis 1991, Toolis 1995). The desire of and dying (Figure 1). Sweeting and Gilhooley (1992) Irish people to die in their homeland is expressed in cur- expand on this and argue that in contemporary society rent literature(Lillis 1991, Toolis 1995)and facilitated by social death can precede biological death, and therefore the services of Funeral Directors advertising in Catholic the stages of dying and associated rituals can no longer be ewspapers(The Universe 1995). Toolis (1995)describes applied(Figure 2). The process starts when the patient is in detail the stages of dying and the rituals associated with admitted with a terminal illness to hospital or institution the death of his father on Achill Island off the west coast (Sweeting Gilhooley 1992). According to Goffman(1963) of Ireland. Again death is accepted as a process by the people entering hospitals undergo the process ofmortifi- dying man and his family and friends, all of which are cation'and become dispossessed of roles they held in taven support by the community. The Irish wake ensures the outside world. Their relatives often feel unwelcome the soul of the dead is protected and the relatives are and uncomfortable especially in intensive care units comforted (Toolis 1995). As in the Jewish tradition there (Rinpoche 1995) is common remembrance of dead relatives throughout the There is a takeover of the body by the professionals who year on certain holy days when grief is shared and support have developed their own rituals (Illich 1990, Sweeting iven(Harty 1975, Cytron 1993) Gilhooley 1992). Being scientists in the positivistic mould, It is perhaps not unexpected that these similarities are doctors have a predilection for slotting the individual into present between Jews and Catholics because their beliefs a hierarchy of terms for death and dying. Sudnow(1967) stem from the same roots(Cytron 1993). Barley (1995)and and Kalish(1968)discuss" biological,, clinical, 'psycho- Irish et al.(1993), however, find similarities in rituals logical'and'social death Each definition is affiliated to a throughout the world. The Toragans of Indonesia travel all set of rituals prescribed by the professionals, none of over Asia to bring the bones of their dead to be buried in which satisfy the spiritual needs of the individual and the rock caves hundreds of feet above the ground in family involved(May 1973, Illich 1990) Sulawesa (Barley 1995). Buddhists and Muslims, the This ritualistic labelling of the dying process of patier Mexican Indians and others keep vigil with the dying by doctors and nurses is thought to be due to contemporary before and after death (Irish et al. 1993, Rinpoche 1995). life becoming so secularized, that the sacral dimensions of Funerals may vary from the simple affairs of the Quakers death are too awesome to admit as a solution(May 1973) to very elaborate ceremonies of the Hmong, but exist in Once a death label has been attached, the individual is some form universally (Irish et al. 1993). Buddhists, perceived as an illness rather than a human being, and Muslims and the Lakota among others recognize anniver- social death, when a person is treated essentially as a saries with ceremonies a year after the loved one's death corpse, as in old age or dementia, can occur (Travelbee (Irish et al. 1993). The belief that death is a rite of passage 1971). The effect is to distance the professionals from the from this world to the next is common in all of these beliefs patient and their relatives, and to isolate the patient in a and affirms the power of human society to transcend the kind of limbo where he has little human status(Sweeting death of an individual and conquer death itself (Toolis Gilhooley 1992) 1995). They are beliefs that have survived the passage of Sweeting and Gilhooley (1992)discovered that the with time and the changes described by Illich(1992)(Figure 1). drawal from the dying patient and departure by the family from traditional rituals is all too easy in contemporary Lack of rituals in modern western society society. Death and dying are no longer a family affair. Knutson(1970)sees the professionals as developing rituals Many contemporary authors agree that western affluent which provide the means for society to dissociate itself societies are unable to look upon death and its rituals as from death and dying. The hospital or institution takes a right of passage to be compared with birth, coming of over the care of the individual prior to death(Illich 1990) age, marriage and retirement. Barley (1995)argues that we The funeral director arranges for the preparation of the have turned our mortality over to the social workers and body, resorting to all the technology of the day so that the with it many of the rituals which gave it meaning. corpse looks as'natural'as possible(May 1973). Cremation @1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127-113

S.M. O’Gorman The first anniversary ‘yahrzeit’ is marked by the family Rinpoche (1995) was shocked by the contrast of lack of gathering at the cemetery to reflect on the life of the positive rituals in the West to those which attest to the deceased. It is usual at this time to dedicate the tombstone majestic vision of life and death underlying Tibetan tra￾and Sweeting and Gilhooley (1992) describe this as the dition. Toolis (1995) acknowledges the negative effects of third phase in the death ritual, signifying that the deceased the hushed reverence and deep embarrassment normally is now regarded as a dead ancestor. Helman (1985) sees associated with the Anglo-Saxon rituals surrounding this as the last of a series of funerals during which the death. Cytron (1993) condemns the ‘fast grief’ of modern diseased gradually leaves the land of the living. American Jews and speculates that this is due to seculariz￾There are many similarities between Jewish rituals and ation and medicalization of terminal care. those of other communities such as rural Ireland (Keane Illich (1990) demonstrated the medicalization of death 1985, Taylor 1988, Lillis 1991, Toolis 1995). The desire of and dying (Figure 1). Sweeting and Gilhooley (1992) Irish people to die in their homeland is expressed in cur- expand on this and argue that in contemporary society rent literature (Lillis 1991, Toolis 1995) and facilitated by social death can precede biological death, and therefore the services of Funeral Directors advertising in Catholic the stages of dying and associated rituals can no longer be newspapers (The Universe 1995). Toolis (1995) describes applied (Figure 2). The process starts when the patient is in detail the stages of dying and the rituals associated with admitted with a terminal illness to hospital or institution the death of his father on Achill Island off the west coast (Sweeting & Gilhooley 1992). According to Goffman (1963) of Ireland. Again death is accepted as a process by the people entering hospitals undergo the process of ‘mortifi- dying man and his family and friends, all of which are cation’ and become dispossessed of roles they held in given support by the community. The Irish wake ensures the outside world. Their relatives often feel unwelcome that the soul of the dead is protected and the relatives are and uncomfortable especially in intensive care units comforted (Toolis 1995). As in the Jewish tradition there (Rinpoche 1995). is common remembrance of dead relatives throughout the There is a takeover of the body by the professionals who year on certain holy days when grief is shared and support have developed their own rituals (Illich 1990, Sweeting & given (Harty 1975, Cytron 1993). Gilhooley 1992). Being scientists in the positivistic mould, It is perhaps not unexpected that these similarities are doctors have a predilection for slotting the individual into present between Jews and Catholics because their beliefs a hierarchy of terms for death and dying. Sudnow (1967) stem from the same roots (Cytron 1993). Barley (1995) and and Kalish (1968) discuss ‘biological’, ‘clinical’, ‘psycho￾Irish et al. (1993), however, find similarities in rituals logical’ and ‘social’ death. Each definition is affiliated to a throughout the world. The Toragans of Indonesia travel all set of rituals prescribed by the professionals, none of over Asia to bring the bones of their dead to be buried in which satisfy the spiritual needs of the individual and the the rock caves hundreds of feet above the ground in family involved (May 1973, Illich 1990). Sulawesa (Barley 1995). Buddhists and Muslims, the This ritualistic labelling of the dying process of patients Mexican Indians and others keep vigil with the dying by doctors and nurses is thought to be due to contemporary before and after death (Irish et al. 1993, Rinpoche 1995). life becoming so secularized, that the sacral dimensions of Funerals may vary from the simple affairs of the Quakers death are too awesome to admit as a solution (May 1973). to very elaborate ceremonies of the Hmong, but exist in Once a death label has been attached, the individual is some form universally (Irish et al. 1993). Buddhists, perceived as an illness rather than a human being, and Muslims and the Lakota among others recognize anniver- social death, when a person is treated essentially as a saries with ceremonies a year after the loved one’s death corpse, as in old age or dementia, can occur (Travelbee (Irish et al. 1993). The belief that death is a rite of passage 1971). The effect is to distance the professionals from the from this world to the next is common in all of these beliefs patient and their relatives, and to isolate the patient in a and affirms the power of human society to transcend the kind of limbo where he has little human status (Sweeting death of an individual and conquer death itself (Toolis & Gilhooley 1992). 1995). They are beliefs that have survived the passage of Sweeting and Gilhooley (1992) discovered that the with￾time and the changes described by Illich (1992) (Figure 1). drawal from the dying patient and departure by the family from traditional rituals is all too easy in contemporary society. Death and dying are no longer a family affair. Lack of rituals in modern western society Knutson (1970) sees the professionals as developing rituals Many contemporary authors agree that western affluent which provide the means for society to dissociate itself societies are unable to look upon death and its rituals as from death and dying. The hospital or institution takes a right of passage to be compared with birth, coming of over the care of the individual prior to death (Illich 1990). age, marriage and retirement. Barley (1995) argues that we The funeral director arranges for the preparation of the have turned our mortality over to the social workers and body, resorting to all the technology of the day so that the with it many of the rituals which gave it meaning. corpse looks as ‘natural’ as possible (May 1973). Cremation 1132 © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127–1135

Death and dying in contemporary society seems for many nowadays to be a clean and accelerated the author's own experiences. It was a communal affair way of avoiding the horrors of physical decay and the cost The individual and the relatives were never alone. Death of an expensive gravestone(Barley 1995). Grief is seen as and dying were a part of everyday life and grief expressed a disease and in a culture rooted in Puritanism needs to during the ordinary daily routines of life be 'worked out and'gotten over(Becker 1969) The Irish wake seemed incomprehensible to Sweeting and Gilhooley (1992)question whether the was versed in the Anglo-Saxon ways. The body, changes depicted in Figure 2 are desirable. According to by a member of the family, in order to receive y, lad ou May (1973)and Illich(1990)nothing has affected quality blessing,, would be in the parlour of a country house sur- of life in the last 200 years and our objective capacity to rounded by flowers from the garden and lighted candles ope with the powers that beset us than the application of Toolis (1995) and Taylor(1988) relate how children are technology to disease and death. The individual dies alone encouraged to visit the dying and to view the corpse. When in an institution without family support and ostracized by visitors had paid their last respects they would join the doctors and nurses(Kubler-Ross 1970, Travelbee 1971). crowd in the kitchen who would then spend all night According to Fulton and Fulton(1971)when a label of recounting stories associated with the dead person. social death has been applied relatives experience antici- Alcohol would be supplied liberally and by the end of the patory grief and will have already worked it through to night to the uninitiated the event would appear to be more resolution by the time biological death occurs. Parkes like a party than a melancholy event. Initially the whole (1986), however, disputes this and claims that grief can be process appeared to the author to be in ' the worst intensified due to the way it is socially defined and struc- possible taste tured in society. Charmaz (1980) suggests that the contem- Enlightenment comes with age and experience, and with porary rituals which force individuals to handle grief it the realization that in shunning death we are futilely independently give rise to high disease and death rates denying our human nature. Like Toolis (1995 )the author among them now believes that rituals like the irish wake celebrate death as a happy occasion and bestow grace upon those leaving life and upon a community of those who mourn them. COMPARISON OF RITUALS IN ENGLAND AND IRELAND: A PERSONAL EXPERIENCE The author's personal experiences mirror those of Toolis CONCLUSION (1995). Rituals associated with the death of a family The model( Figure 1)presented in this paper gives an over- member in England are very different from those in rural view of the development of contemporary attitudes to Ireland even though the basic Catholic religious belief be death and dying and their relevance to recent understand- the same. The author's memory of the death of a mother ings of health and healing. The ultimate professionaliz of a comparatively young family in the 1950s recalls ation of death which removed western society away from Toolis's (1995) Protestant hushed respectfulness which the process of death is demonstrated. Figure 2 had somehow infiltrated and taken over a Catholic com- the rituals associated with'primitive' and modern western munity. The funeral director removed the body from the societies and establishes that in the latter, traditional rit- home to be prepared for burial. Very little grief was uals have been truncated and therefore the expression of expressed or encouraged. The children continued to go grief denied to school and were boarded out to relatives lest they saw Analysis of the facts confirmed by the model reveals that too much or became involved with the process of death. contemporary society has endangered health by being This personal experience embodies Charmaz'(1980) unable to discuss death. Fear of death and unresolved grief observation that beyond the truncated set of rituals can cause anxiety, depression and physical disease. Those mpanying the funeral, little public acknowledgement cultures which have retained traditional rituals are able to enced for a short period, and because other rituals of their lives e fear of death and are qualified to optimize oss is made in contemporary society. Grief was experi- overcome th expression were not observed the actual process was never There is a dawning realization that contemporary atti completed or the grief resolved(Parkes 1986) tudes to death and dying are unsatisfactory and that In contrast the author's first experiences of death and society has somehow lost touch with the meaning of life dying in rural Ireland were totally disparate and came as The proliferation of thanatology research and literature an unpleasant shock. There were elements of shamanic proves this misgiving amongst professionals responsible practices in the emphasis on the significance of tribe and for death education. There is recognition of the value of community, use of herbs in healing their positive perspec- primordial teachings and other religions and beliefs, in tive on death and dying(Birmingham 1911, Taylor 1988, the treatment of physical and mental illness and the Money 1994). Recent descriptions by Toolis(1995)revive promotion of good health. Individuals have woken up to 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127-1135 1133

Death and dying in contemporary society seems for many nowadays to be a clean and accelerated the author’s own experiences. It was a communal affair. way of avoiding the horrors of physical decay and the cost The individual and the relatives were never alone. Death of an expensive gravestone (Barley 1995). Grief is seen as and dying were a part of everyday life and grief expressed a disease and in a culture rooted in Puritanism needs to during the ordinary daily routines of life. be ‘worked out’ and ‘gotten over’ (Becker 1969). The Irish wake seemed incomprehensible to one who Sweeting and Gilhooley (1992) question whether the was versed in the Anglo-Saxon ways. The body, laid out changes depicted in Figure 2 are desirable. According to by a member of the family, in order to receive ‘a special May (1973) and Illich (1990) nothing has affected quality blessing’, would be in the parlour of a country house sur￾of life in the last 200 years and our objective capacity to rounded by flowers from the garden and lighted candles. cope with the powers that beset us than the application of Toolis (1995) and Taylor (1988) relate how children are technology to disease and death. The individual dies alone encouraged to visit the dying and to view the corpse. When in an institution without family support and ostracized by visitors had paid their last respects they would join the doctors and nurses (Kubler-Ross 1970, Travelbee 1971). crowd in the kitchen who would then spend all night According to Fulton and Fulton (1971) when a label of recounting stories associated with the dead person. social death has been applied relatives experience antici- Alcohol would be supplied liberally and by the end of the patory grief and will have already worked it through to night to the uninitiated the event would appear to be more resolution by the time biological death occurs. Parkes like a party than a melancholy event. Initially the whole (1986), however, disputes this and claims that grief can be process appeared to the author to be in ‘the worst intensified due to the way it is socially defined and struc- possible taste’. tured in society. Charmaz (1980) suggests that the contem- Enlightenment comes with age and experience, and with porary rituals which force individuals to handle grief it the realization that in shunning death we are futilely independently give rise to high disease and death rates denying our human nature. Like Toolis (1995) the author among them. now believes that rituals like the Irish wake celebrate death as a happy occasion and bestow grace upon those leaving life and upon a community of those who mourn them. COMPARISON OF RITUALS IN ENGLAND AND IRELAND: A PERSONAL EXPERIENCE CONCLUSION The author’s personal experiences mirror those of Toolis (1995). Rituals associated with the death of a family The model (Figure 1) presented in this paper gives an over￾member in England are very different from those in rural view of the development of contemporary attitudes to Ireland even though the basic Catholic religious belief be death and dying and their relevance to recent understand￾the same. The author’s memory of the death of a mother ings of health and healing. The ultimate professionaliz￾of a comparatively young family in the 1950s recalls ation of death which removed western society away from Toolis’s (1995) Protestant hushed respectfulness which the process of death is demonstrated. Figure 2 compares had somehow infiltrated and taken over a Catholic com- the rituals associated with ‘primitive’ and modern western munity. The funeral director removed the body from the societies and establishes that in the latter, traditional rit￾home to be prepared for burial. Very little grief was uals have been truncated and therefore the expression of expressed or encouraged. The children continued to go grief denied. to school and were boarded out to relatives lest they saw Analysis of the facts confirmed by the model reveals that too much or became involved with the process of death. contemporary society has endangered health by being This personal experience embodies Charmaz’ (1980) unable to discuss death. Fear of death and unresolved grief observation that beyond the truncated set of rituals can cause anxiety, depression and physical disease. Those accompanying the funeral, little public acknowledgement cultures which have retained traditional rituals are able to of loss is made in contemporary society. Grief was experi- overcome the fear of death and are qualified to optimize enced for a short period, and because other rituals of their lives. expression were not observed the actual process was never There is a dawning realization that contemporary atti￾completed or the grief resolved (Parkes 1986). tudes to death and dying are unsatisfactory and that In contrast the author’s first experiences of death and society has somehow lost touch with the meaning of life. dying in rural Ireland were totally disparate and came as The proliferation of thanatology research and literature an unpleasant shock. There were elements of shamanic proves this misgiving amongst professionals responsible practices in the emphasis on the significance of tribe and for death education. There is recognition of the value of community, use of herbs in healing, their positive perspec- primordial teachings and other religions and beliefs, in tive on death and dying (Birmingham 1911, Taylor 1988, the treatment of physical and mental illness and the Money 1994). Recent descriptions by Toolis (1995) revive promotion of good health. Individuals have woken up to © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127–1135 1133

S.M. GOrman the fact that there is no cure for mortality, that there are Harty M (1975) The Roman Missal. C B.C.(Belfast), Belfast. limits to life and that it is essential to recognize this so Helgeland J. (1985) The symbolism of death in the late Middle that they can learn to live positively and without the fear Ages. Omega 15(2),145-157 of death Helman C(1985)Culture, Health and Illness. Wright, Bristol The personal reflections discussed in the essay have Holbein H (1971)The Dance of Death. Dover, London done much to clarify the author's own beliefs and values Ikeda D.(1988)Unlocking the Mysteries of Birth and Death regarding death. The rituals observed and the death edu- Illich I.(1990) Limits to Medicine. Penguin, Harmondsworth cation received in childhood were destructive and under- Illich I(1992)Disabling Professions. Marion Boyars, London mined the development of a healthy philosophy for life. Irish D P, Lundquist K.F. Nelson v.(1993)Ethnic variations Experience of attitudes to life and death in rural Ireland in Dying Death and Grief. Taylor and Francis,London introduced a new perspective, which although at first Kalish R.(1968) Life and death- dividing the invisible. Soci rejected, eventually became the essence of an adult philos- Science and Medicine 2, 249-259 ophy. It is a philosophy which encompasses ideas from Keane J(1985)Owl Sandwiches. Brandon, Co. Kerry, Ireland Shamanism, Buddhism, Christianity and the holistic Knutson A(1970)Cultural beliefs on life and death. In The spectives of contemporary health issues. It has served Patient (Brim O, Freeman H, Levine S.&Sca primitive'communities well in sickness and in health and Russell Sage Foundation, New York, Pp 42-6 otch N. eds. J at the hour of their death Kubler-Ross E(1970)On Death and Dying. Tavistock, London. Lillis K (1991)Kieran Lillis Remembers. Clare Champion Printers, Co Clare, Ireland. Acknowledgement Maddi S& Costa P.(1972)Humanism in Personology: Allport, The author wishes to express her sincere gratitude to Liz May WE(1973)The sacral power of death in contemporary Buckley MSc BA (Hons) RNT RCNT RGN SCM RMN for experience. In Death an American Experience(Mack A.& her help and encouragement, constructive criticism and Parsons T eds), Shocken Books, New York suggestions for the development of this paper McNeil W.(1976)Plagues and Peoples. Basil, Blackwell, Oxford Mello A. de(1983)Sadhama a Way to God. Anand Press References Mellor P.A.(1993)Death in high modernity: the contemporary presence and absence of death. In The Sociology of Death Acring C D (1971) The Understanding Physician. Detroit Wayne (Cla ) Blackwell Science, Oxford, pp. 11-30 State Unive Money M. (1994) Shamanism and health. Journal of Barley N.(1995)Dancing on the Grave. John Murray, London Contemporary Health 1(1),40-43 Becker H. (1969) The sorrow of bereavement. In Death: Moody R. 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Journal of Barley N. (1995) Dancing on the Grave. John Murray, London. Contemporary Health 1(1), 40–43. Becker H. (1969) The sorrow of bereavement. In Death: Moody R. & Perry P. (1988) The Light Beyond. Bantam, New York. Interpretations (Ruitenbeek H.M. ed.), Delta Books, New York, O’Connor C. (1966) The Art of Dying Well: The Development of pp. 32–46. the Ars Moriendi. AMS Press, New York. Bertman S.L. (1991) Facing Death. Hemisphere, London. Parkes C.M. (1986) Bereavement Studies of Grief in Adult Life. Birmingham B.A. (1911) The Lighter Side of Irish Life. T.N. Tavistock, London. Foulis, London. Pietroni P. (1991) The Greening of Medicine. Victor Gollanaz, Charmaz K. (1980) Social Reality of Death: Death in London. Contemporary America. Addison Wesley, London. Ramsey P. (1974) The Indignity of Death. Hastings Centre Cytron B.D. (1993) To honor the dead and comfort the mourners: Study, Hastings. traditions in Judaism. In Ethnic Variations in Dying, Death and Ring K. (1985) Heading Towards Omega. Marrow, New York. Grief (Irish D.P. et al. eds), Taylor and Francis, London, Rinpoche S. (1995) The Tibetan Book of Living and Dying. pp. 113–123. Rider, London. Draper P. (1991) Health Through Public Policy. Green Print, The Sacks O. (1982) Awakenings. Picador, London. Merlin Press, London. Saunders C. (1979) The Management of Terminal Disease. Edward Dubos R. (1959) The Development of Modern Medicine: An Arnold, London. Interpretation of the Social and Scientific factors Involved 2nd Seedhouse D. (1992) Health, The Foundations of Achievement. edn. Knopf, New York. J. Wiley and Sons, New York. Elias N. (1985) The Loneliness of Dying. Basil Blackwell, Oxford. Shryock R.N. (1947) The Development of Modern Medicine. An Foucault M. (1991) The Foucault Reader (Rabinow P. ed.) Interpretation of the Social and Scientific Factors Involved 2nd Penguin, Harmondsworth. edn. Knopf, New York. Fulton R. & Fulton J. (1971) A psychological aspect of terminal Sudnow D. 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Death and dying in contemporary society The Universe (1995) Funeral directors. In The Universe Travelbee J(1971)Interpersonal Aspects of Nursing 2nd edn. F.A. newspaper, Sunday, 27 October, Gabriel Communications, Davis, Philadelphia Tuchman B. (1978)A Distant Mirror: The Calamitous 14th Toolis K(1995)Death. An Irish wake and Anglo Saxon attitudes. Century. Alfred A. Knopf, New York. he Guardian Weekend 7 October, Guardian Newspapers, Wahl C W.(1959)The fear of death In Meaning of Death(Fiefel H pp.14-21 ed. ) McGraw-Hill, New York, pp 16-29 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127-1135 1135

Death and dying in contemporary society The Universe (1995) Funeral directors. In The Universe Travelbee J. (1971) Interpersonal Aspects of Nursing 2nd edn. F.A. newspaper, Sunday, 27 October, Gabriel Communications, Davis, Philadelphia. p. 27. Tuchman B. (1978) A Distant Mirror: The Calamitous 14th Toolis K. (1995) Death. An Irish wake and Anglo Saxon attitudes. Century. Alfred A. Knopf, New York. The Guardian Weekend 7 October, Guardian Newspapers, Wahl C.W. (1959) The fear of death. In Meaning of Death (Fiefel H. pp. 14–21. ed.), McGraw-Hill, New York, pp. 16–29. © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 1127–1135 1135