- 1 Department of Psychology, University of Bielefeld, Germany.
- PMID: 30373472
- DOI: 10.1177/0030222818808145
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- 1 Department of Psychology, University of Bielefeld, Germany.
- PMID: 30373472
- DOI: 10.1177/0030222818808145
How anxious are you about dying? According to Tomer and Eliason, this depends on various personal circumstances, which they identified in their model on death anxiety. This study aims to verify various aspects of Tomer and Eliason’s theoretical model. We therefore collected data from 652 German participants about demographic variables, religiosity, life satisfaction, death acceptance, and death anxiety. We then conducted a path analysis in order to verify whether the empirical data supported the theoretical model. Our results demonstrate a very good model fit, indicating that the analyzed model is valid and can be maintained. Further mediation analysis demonstrates the specific relations of variables within the model and their influence on death anxiety.
Keywords: attitudes toward death; death; death anxiety; religion or spirituality; thanatology.
Aside from birth, the only other thing that is guaranteed to happen to every single person on the planet is death. No exceptions, no way around it. Your own death aside, chances are good that you will be affected by deaths of loved ones and most likely have to plan a funeral or two before your own comes about.
People who think and talk about death a lot are often labeled “morbid,” or “death obsessed.” Guilty as charged, I suppose. But that’s exactly what I recommend doing. Learn all you can, talk about your own mortality and funeral wishes, talk to your friends and family about theirs. Most people won’t want to — one of the downsides to being a conscious human is the awareness that someday you will die, and it’s normal for that to scare the hell out of you. Death-denial is the default in modern Western culture, to the point that we attempt to extend life past the point of sense and hire people to dress and make up the corpses of our loved ones to create an allegedly comforting “memory picture.”
Here, I will present some ways to think and talk about mortality that will hopefully make you relax a bit about it, manage the anxiety, and maybe be able to let go.
How and Where to Start Talking About Death
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Luckily, as the past five years or so has ushered in an exciting era of Death Positivity, there are more and more opportunities to consider your own death, and to plan for it. This is by no means an exhaustive list, but a sampling of some of the organizations or events you could take part in that can help ease death anxiety.
- YG2D(You’re Going to Die) in San Francisco is an “open space where people can share their thoughts and feelings about death.” It usually takes the form of an open-mic night, described as “bringing people creatively into the conversation of death and dying while helping to inspire and empower them out of the context of unabashedly confronting loss and mortality.”
- Death Cafe was started in 2011 in London, but now exist all over the world . They are casual gatherings described as just getting together to drink tea, eat cakes, and talk about death, without an agenda.
- Death Salon is a group of funeral directors, artists, intellectuals, authors, and “independent thinkers who aim to subvert death denial by opening up conversations with the public about death and its anthropological, historical, and artistic contributions to culture.” They have hosted events in Los Angeles, Philadelphia, and more. The next scheduled gatherings are in Seattle and Boston.
- The Death Talk Project , based in Portland, Oregon, seeks “to stimulate useful, honest conversation about how we die, how we mourn, and how we care for and remember our dead.” They also host workshops, Death Cafes, movie nights, and other events to bring people together into a community to confront how they relate to death and dying.
- Mortalls (“what to talk about before time runs out”), is a “death-positive conversation game.” Starting a conversation about death and dying is difficult and awkward, perhaps even more so when done in a family setting. But now you have no excuse — and it may even be fun.
Chris Raymond is an expert on funerals, grief, and end-of-life issues, as well as the former editor of the world’s most widely read magazine for funeral directors.
Carly Snyder, MD, is a board-certified reproductive and perinatal psychiatrist who combines traditional psychiatry with integrative medicine-based treatments.
James Lacy, MLS, is a fact-checker and researcher. James received a Master of Library Science degree from Dominican University.
While the sudden, unexpected death of a loved one can unleash a torrent of anguish and grief, a family member or friend who departs from the living over days, weeks, months or even longer can prove just as traumatic for survivors because of anticipatory grief — the sadness felt in advance of the death.
Tips for Coping With Anticipatory Grief
Here are a few of the emotional challenges you might encounter as you attempt to cope with the impending death of your loved one, and suggestions to help you deal with them.
Regardless of whether you are serving as a caregiver or not, knowing that your loved one’s time is limited will take a toll on your physical and emotional strength. People can only live effectively in a “state of emergency” for a short period.
While that length of time will vary depending on the person and the situation, once that limit is reached, the mind and senses will begin to shut down as a self-preservation measure. This can manifest itself in many ways, including:
- An overwhelming need to sleep
- Lack of concentration
- An emotional “numbness” or detachment
It is important to understand that these feelings are perfectly normal and do not mean you are cold or unfeeling. Eventually, your body and mind will recover, and you will feel normal again — until something else triggers a state of heightened emotional response. You should expect to experience such waves of feeling and to view the times when you shut down as necessary and healthy.
That said, make sure you also get enough sleep, eat properly, spend time with other family members or friends, and can recognize the signs of caregiver burnout.
Death is a difficult subject for most people to talk about, and particularly so when we must bear witness to the protracted death of a loved one.
Because we feel uncomfortable, we often begin making assumptions in our head about what our loved one does or doesn’t wish to talk about concerning their impending death, such as, “If I express how much I will miss him, it will make him feel worse,” or “I won’t say goodbye until the very end so she and I can find some happiness in the time remaining.”
The net effect of such internal conversations is often that nothing is said, which can actually make a dying person feel isolated, ignored or alone.
As difficult as it might feel right now, open and direct communication is the best way to interact with a dying loved one. Let him or her know that you would like to talk about how you are feeling, as well as what you can provide during the time remaining in terms of support and comfort.
Once the honest conversation begins, you might discover that your fear of having this conversation was overblown.
When someone we love is diagnosed with a terminal illness, it is very easy to focus all of our attention and energy on the patient almost to the exclusion of our own needs. The strain caused by caring for a dying loved one — particularly for those providing a significant amount of the care — can often lead to caregiver stress as the physical, emotional and even financial impacts take their toll.
While it might seem unthinkable, caregiver stress can lead to feelings of resentment, anger or frustration toward the dying patient — and those feelings often trigger a profound sense of guilt. If left untreated, such emotions can seriously complicate the grief one feels after the patient dies, putting you at risk of depression, thoughts of suicide or post-traumatic stress disorder.
If you exhibit signs of caregiver stress, you should immediately talk to your family or friends and say, “I need help.” Ideally, someone can assume some of the responsibility that you have shouldered, even temporarily, in order to give you a break and alleviate some of your stress.
If that is not an option, then consider a more formal type of respite care, such as an adult day-care facility or hiring an in-home caregiver, in order to give yourself the break you need.
While it might seem difficult to force yourself to let go temporarily, you will return more refreshed and energetic and provide much better care to your dying loved one.
The emotional toll on a surgeon or physician after the loss of a patient is an experience rarely spoken about freely. Perhaps the one exception is during the mandatory review at morbidity and mortality conference. We are often not prepared on how to deal with this experience. There is no grief counseling after the fact and sometimes no time to reflect on the depth of its impact. How one deals with a patients’ expected or unexpected passing is based on their perspective on life, the circumstances, and of course likely the manner in which they learned as trainees.
The conditions surrounding the loss will directly impact the spectrum of emotions felt. For example, if it is a patient with cancer that you have cared for and death is expected you might feel some loss but as it was expected you are more emotionally prepared for that likely outcome. However, the death of a trauma patient that you did not know previously might elicit sadness for the loss of a human life; but may not affect you profoundly unless it’s the first time that you have had the experience. Likely the hardest scenario is a patient death when the outcome was unexpected or intraoperative.
The range of emotions can range from no impact to a deep sense of loss, anger, astonishment, helplessness or worse an acute depression. Hopefully as you work through the reactions you will develop a deeper sense of appreciation for your profession and the role you play in saving lives. We are surgeons, we are brave and confident yet we must be prepared to deal with this inevitable occurrence.
How can you prepare? A family member once said to me “you are a surgeon you should expect that you would lose a patient.” But even still it’s hard to say that the expectation gives solace. Frankly it would leave us vulnerable to believe a patient can die as we invade the body wielding our knives, clamps and ties with confidence. To be effective the thought can never really be at the forefront of our mind during an operation. We focus instead on attaining the best outcome. We prepare the patient and our team for the case especially if it is a challenging one. If religious, we say a silent prayer for success.
What happens after you do lose a patient? From a systematic standpoint there really is nothing in place to help a surgeon through the grieving process. You grieve, you mourn privately. You turn within promising to be better, to learn and to not let that death be in vain. Every year 200,000 lives are lost due to medical error alone. We are not infallible; we are mere humans and can not save the life of every patient we treat.
Over my career I have had to deal with the loss of patients in all the scenarios I described. The ones that are closest to me are the most challenging but they have all been challenging. I hold the memory of all close so that their deaths whether expected or not can serve as an instruction on how to be the best surgeon, colleague, provider and teacher I can be. Fortunately it is not a frequent occurrence as I am moved quite deeply with sorrow when it does occur.
I have learned some lessons and coping skills that I will now share. You will have developed some on your own and I would love to hear about them (Twitter – @KMarieMD).
- Be there for the family – This is the most important recommendation. No matter how you are feeling (or not) they have lost a loved one. Even if it was expected it remains devastating. Show empathy, be truthful and be available.
- Seek the guidance of a trusted senior surgeon – Most if not all have had this experience at some point in their career. They will have likely found a way to cope that they might share. They will also be able to offer insight on what decisions could have been optimized for a particular case.
- Seek the support of your family/friends– However challenging the whirlwind of emotions you might face, remember your commitment to saving lives. You contributions to society are important. Mourn and seek comfort. Then return to doing what you do best.
- Perform an introspective analysis– Determine what lessons can be learned that will help you and your team to grow. Look for and be open to feedback.
- Support your team – Review the case with your team. Allow everyone to have a voice in expressing what occurred, how the case was managed and what can be improved. This is especially important in unplanned deaths. Model for your team empathy, kindness and openness to receiving feedback.
- Consider attending the funeral – This will be based on the closeness of the relationship with the patient and the family. I have personally attended a couple of my patients’ funerals. I got closure from the process and their family appreciated my presence.
- Write a personal note to the family if the death occurred outside of the hospital. Even if you took care of the patient a long time ago your note may help a loved one.
- Reach out to a colleague that has lost a patient – a kind word and advice will undoubtedly help.
- Seek professional help – If a case troubles deeply you might need to discuss the case with a grief specialist. An unexpected outcome can lead to post traumatic stress. Know you are not alone even if this result is not openly discussed.
- Prepare your patients – Death unfortunately will occur. Be mindful in setting expectations in the preoperative setting especially for challenging cases. If a patient has a terminal condition discuss early the potential of death. Obtain do not resuscitate (DNR) and do not intubate orders (DNI) early in the relationship. A prepared patient and family can make decisions with clarity if they have an accurate vision of the future and time to process.
I recommend the following publications for more advice and examples about how to deal with a patient’s death.
Share your thoughts with me on this topic @KMarieMD.