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This is my play’s last scene:Death Rituals in America
GEC Faculty ScholarsJuly 26, 2013
Michael D. Barnett, MD, MS
Assistant Professor of Medicine & Pediatrics
UAB Center for Palliative & Supportive Care
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Objectives
1. To describe the importance of ritual in death and dying.
2. To list common cultural customs surrounding death in America.
3. To recognize our role in the death rituals of our patients.
4. To reflect on ritual as part of our personal grieving process as clinicians.
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Universality
Death of elderly chimpanzee at a zoo in UK, 2010.
Pre-death caregivingAll-night vigil at time of deathTesting for signs of lifeMale aggression towards corpseCleaning of the bodyMourning period
Anderson, JR, et al. (2010) Current Bio. 20(8):R349-51.
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Rituals
Arnold van Gennep, French folklorist, published his model on rites of passage in 1960.
Hunter, J. (2008) OMEGA. 56(2):153-73.
Separation Transition Reintegration
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Death Rituals
Rites of passage that serve specific purposes surrounding death:
1. Provide social support to mourners.2. Set limits to formal mourning.3. Outline cultural obligations during mourning.4. Restore the bereaved to society.
Hunter, J. (2008) OMEGA. 56(2):153-73.
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Death Rituals
Medicine
Religion/
Spirituality
Psychology
Sociology
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Dying in America
In 2007, there were 2.4 million adult deaths in US
50-90% of adults prefer to die at home. 50-60% of adults die in the hospital.
We are players in our patient’s last scene.
Xu, J., et al. (2010) National Vital Statistics Report, 58(19).Bell, CL, et al. (2010) J Pain Symptom Manage. 39(3):591-604.
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Anatomy of a Scene
Preparing for deathPreparing the bodyPreparing for burialPreparing for life apart
African AmericanHinduIslamicJewishWestern (Christian)
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African American
“No one has power over the wind to restrain the wind, or power over the day of death.”
- Ecclesiastes 8:8
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background
Blending of African & Christian traditions
Death as “transition”
More familiarity with death
Mistrust of hospitals & physicians
Personal reflections of rituals…Collins, WT & A. Doolittle (2006) Death Studies, 30:957-69.McIlwain, CD (2002) Qual. Res Reports in Comm., Winter 2002:1-6.
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Preparing for Death
Importance of community:Physically gathering at the bedsideGroup decision-making
Medical decisions & funeral services often delayed
Barrett, RK & KS Heller (2002) J Palliat Med. 5(5):793-800.
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Preparing for Burial
The wake or “sit up”Body brought back home if possible”Home-going” celebrationDisplay of respect (i.e. giving them the best)
Emotional displays may be expected or encouraged
Barrett, RK & KS Heller (2002) J Palliat Med, 5(5):793-800.McIlwain, CD (2002) Qual. Res Reports in Comm., Winter 2002:1-6.
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Preparing for burial
New Orleans Jazz Funeral
Procession of band, casket, family & friends Display of solidarity (“second-line”) Dirge progressing to upbeat music
Passes by places important to deceased
Bordere, TC (2008) OMEGA, 58(3):213-32.
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Preparing for Life Apart
T-shirts & tattoos as symbols of remembrance
Photo, name, birthday, date of death “Gone but not forgotten”
Bordere, TC (2008) OMEGA, 58(3):213-32.
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Hindu“Because death is certain for the one who is born, and birth is certain for the one who dies. Therefore, you
should not lament over the inevitable.” - Bhagavad-Gita 2:27
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Background
Karma—birth & death part of cycle of actions which lead to reincarnation or absorption into Brahman
Multiple deities, each with devoted following: Brahma (the Creator) Vishnu (the Preserver) Shiva (the Destroyer)
Clements, PT, et al. (2003) J Psychosocial Nurs, 41(7):18-26.
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Preparing for death
Fasting Singing of hymns (bhajans)
Body laid on ground just before death with head facing south
Firth, S. (2005) Lancet, 366:682-6.
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Preparing for death
“Good” death: Old age Right astrological time Right place
Shining forehead Peaceful expression Eyes & mouth open
“Bad” death: Premature Violent Wrong time Wrong place
Unpleasant expression Vomit, urine or feces
Firth, S. (2005) Lancet, 366:682-6.
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Preparing the body
Body bathed, massaged with oils, dressed in new clothesGanges water on lipsBasil (tulasi) leaf in mouthEyes & mouth left open
Sacred ash (bhasma) or sandalwood paste applied to forehead
Firth, S. (2005) Lancet, 366:682-6.
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Preparing for burial
Antyesti—funeral rites Oldest son (or priest) places flowers around body &
lights funeral pyre Ideally before next sunrise
Lobar, SL, et al. (2006) Pediatr Nurs, 32(1):44-50.
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Preparing for life apart
Formal mourning—10 days of prayer & abstinence Oil lamp kept lit at home On 10th day, lamp taken to water & released
Shradh—month-long ceremony at 1st anniversary Prayers made for the deceased Food given to poor Restrictions on new clothes & parties
Clements, PT, et al. (2003) J Psychosoc Nurs, 41(7):18-26.
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Islamic“Wherever you are, death will overtake you, though you are in lofty towers.”
- Qur’an 4:78
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background
Shari-ah (Muslim law) derived from Hadith (practice & sayings of Muhammad)
Maut—signs of death:1. Legs become limp2. Breathing becomes heavy & erratic3. Nose bends slightly4. Temples sag
Gatrad, AR (1994) BMJ, 309:521-3.Sarhill, N, et al. (2001) Am J Hospice Palliat Care, 18:251-5.
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Preparing for death
Death seen as a chance to recite or redeclare faith
Use of talismans or lockets “Consumption” of verses
Lundquist, A, et al. (2003) J Perinatal Neonatal Nurs, 17(1):77-86.Sarhill, N, et al. (2001) Am J Hospice Palliat Care, 18:251-5.
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Preparing the body
Face turned to Mecca (or southeast or right)Mouth & eyes are closedRitually bathedWrapped in shroud (kafn)
Body kept intactNo organ donationNo mementos of deceased
Gatrad, AR (1994) BMJ, 309(6953):521-3.Lundquist, A, et al. (2003) J Perinatal Neonatal Nurs, 17(1):77-86.Sarhill, N, et al. (2001) Am J Hospice Palliat Care, 18:251-5.
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Preparing for burial
Burial within 24 hours preferablyNo embalming or cremationNo open casketsNo coffins or simple coffins onlyNo flowers
No loud wailing or tearing of clothesWomen may not be allowed at funerals or cemeteries
Clements, PT, et al. (2003) J Psychosoc Nurs, 41(7):18-26.Gatrad, AR (1994) BMJ, 309(6953):521-3.Sarhill, N, et al. (2001) Am J Hospice Palliat Care, 18:251-5.
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Preparing for life apart
Formal mourning may last for 3 to 40 days
Iddah (period of waiting)—4 months + 10 days for widows
Shoes removed when entering house of deceasedHead covered when talking about deceased
Gatrad, AR (1994) BMJ, 309(6953):521-3.Sarhill, N, et al. (2001) Am J Hospice Palliat Care, 18:251-5.
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Jewish“He uncovereth deep things out of darkness, and bringeth out to light the shadow of death.”
- Job 12:22
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Background
Three main branches—vary based on adherence to Halakha (Jewish Law)OrthodoxConservativeReformed
Sacred privilege to be present at the time of death
Clements, PT, et al. (2003) J Psychosoc Nurs, 41(7):18-26.Loike, J, et al. (2010) J Palliat Med. 13(10):1267-71.