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

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.

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.

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

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.

Death Rituals

Medicine

Religion/

Spirituality

Psychology

Sociology

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.

Anatomy of a Scene

Preparing for deathPreparing the bodyPreparing for burialPreparing for life apart

African AmericanHinduIslamicJewishWestern (Christian)

African American

“No one has power over the wind to restrain the wind, or power over the day of death.”

- Ecclesiastes 8:8

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.

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.

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.

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.

Preparing for burial

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.

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

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.

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.

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.

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.

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.

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.

Islamic“Wherever you are, death will overtake you, though you are in lofty towers.”

- Qur’an 4:78

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.

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.

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.

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.

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.

Jewish“He uncovereth deep things out of darkness, and bringeth out to light the shadow of death.”

- Job 12:22

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.