黑料网

Thanatology; Death education; Stigma; Curriculum

Thanatology the study of Death as a science is in the process of evolution. However, death has been an interesting subject to humans from time immemorial. All religious scriptures discuss death and aftermath, with no scientific proof. (Rig-Veda, ~1500 BC and Upanishads, ~ 600 BC) [1] Ancient poets and philosophers also emphasized the immortality of the soul. ‘Della Bella Morte’ (of the beautiful death) curated by Anacleto Postiglione in its introductory page, starts with the statement of Lucius Seneca (4 BC- 65 AD), ‘Life without the courage to die is slavery’. Socrates, Spartacus to name a few, voluntarily faced death so as not to fail in their ideals or flee a life unworthy of being lived. In the contemporary scenario where dialogues on Euthanasia and therapeutic relentlessness are being actively discussed, teachings of ancient philosophers do matter a lot. But we are still reluctant to openly discuss the ultimate reality of life.

From ages, birth had been taught, not death. The topic has been stigmatised even today. The term ‘present’ is connected to the idea of being, whereas the term ‘past’ is connected to the idea of nonexistence, and not death. In early 21st century, an estimated 100,000 deaths happen every day globally, due to ageing [2]. This number must be even much bigger in the ongoing state of Pandemic. Dying and death occur wherever life exists, and these events will be followed by grief reactions in human and many animal species [3]. Death education benefits all [4]. Important facets of death education as enumerated by Wass are articulation of goals, consideration of content and perspectives, teaching methods, teacher competencies and evaluation [5].

When medical professionals, especially those who are actively involved in the care of dying people, can equip themselves to deal with the situation more effectively and can make advances in the field through continuous professional development activities, if they are trained in death education. The public can benefit from the accumulated knowledge and wisdom pertaining to Thanatology, when they are confronted with death of their own, their own people of significance or their pet animals.

Formal Thanatology teaching in medical schools is an overlooked and an ill-defined topic. The topic is assumed to be taught when ‘it’ happens, and this ‘it’ may be the first encounter of the medical student with the death of a patient [6]. Survey showed an average medical student receive 6 hours of death education, at best 20 hours in a 5-year medical curriculum. [7]. Also, content of death education is minimal or absent in major professional textbooks even in Geriatrics or Family medicine [8]. Education on death and dying was limited to few occasional lectures and seminars in US medical schools [9]. Medical curriculum in developed countries tend to unrecognized death education. The situation in resource limited countries is not at all different. Being a subject that was not included in any curriculum for long, the topic has been neglected by academic circles.

Incorporation of the topic of Death right from our primary school curriculum to highest possible levels is an important task that has to be accomplished with concerted action. Medical and nursing schools have a limited emphasis on the theme of ‘death.’ Advances in Thanatology created increased death education in universities and professional training levels. Ever since the humankind tried to depersonalise death through institutionalising it, the necessity of more trained personal to deal with this reality became evident. Use of hospice program as an alternative means of caring of dying persons in late sixties of twentieth century [10] witnessed this demand for more trained personal to deal with the death and dying. Hospice played significant role in death education [11]. The most visible effect of new death education was the emergence of Hospice programme. Needs of the terminally ill and dying people were made the State’s responsibility through nursing homes and hospices in affluent countries.

Didactic material for Thanatology education should be included into related courses such as Family medicine, Palliative care, Geriatrics, Ethics, Intensive care. It has to be formally or informally included in the medical and allied curriculum as well, so that the student will be armed enough to manage an emotionally difficult time. A person formally trained in Thanatology can effectively and confidently interact with the dying patient and the family. Even if they are encountering a death for the first time in the professional setting, those with proper training in Thanatology will find such interactions less emotionally draining. A study conducted among nursing students and graduate nurses to identify the difference in the attitudes towards the influence of psychological factors upon the treatment of seriously ill patients, death, autopsy concluded that the death education imparted in them had a durable influence in their life. The awareness created positively influenced the death related attitudes [12].

If the professional course dealing with life is teaching the subject Death to such low level, one cannot expect it in other curricula. A curriculum is prescribed to meet specific educational targets for a particular subject. The meaning and sense for such a subject is often a matter of open debate. Thanatology has not subjected to such a debate in our public domain. Goals of education are set by a variety of factors including the advances in scientific knowledge, the guidelines established by local and international agencies, influence of the prevailing culture, political and religious ideologies and so on. Death is one of the main challenges facing the schools across the world, which include the individual’s death, suicides, terrorism, natural disasters, gender violence etc. The universal and perennial nature of death coupled with own curiosity of children and adolescents towards their own and other deaths poses the challenge in the campuses [13]. Yet school curricula is habitually devoid of death education [14]. Herman Feifel in 1977 [4] suggested to incorporate death education in school curriculum as the Death is a reality and part of our culture .A reasonable awareness on the Death can serve as an antidote to the young population who are exposed to violent deaths they observe in entertainment media [15] ‘Glorification’ of death in the fanatic religious teachings or trivialisation of death in the less privileged communities are both condemnable and can be attended with proper training and education of the naturality of death. Late 1970’s witnessed a surge in the demand for teaching children about death and resource materials for death education n school curriculum has been developed [16, 17].

An intentional incorporation of death education in school curriculum was suggested by Jackson and Colwell [18]. Didactic guidelines and resources such as life cycle, small scale loses, and visit to cemeteries and hospices outlined in the chapter devoted for Death education in schools, written by Carter [19]. Common way to deal with the subject of death in modern homes is through ‘silence’ [20]. This morbid silence in turn will generate unnecessary fear. Informal death education should happen whenever any ‘teachable moment’ happens in our day-to-day life. It can be a birth or death of a sibling, friend, pet or so. Audio-visual media plays a vital role in death education in modern era. The unrealistic portrayal of death by the media should be carefully evaluated in formal settings and by families [21].

Existing death rites and rituals are ineffective in meeting our needs to mourn and to express our feelings of grief. All religions are desperately offering rituals which are not scientifically evaluated, adding more darkness into the vital topic. The influence of religion on death and aftermath is constantly diminuting as the people are becoming increasingly cosmopolitan and having a global perspective on matters affecting their day-to-day life. New death rituals that take contemporary feelings and behaviours into consideration are not yet available [22]. More realistic view of death is the need of the hour. There are numerous indications of avoidance and ambivalence in medical and biological sciences, such as genomics, genetics, proteomics and in new technologies such as nanotechnology and regeneration technology , raise expectations for further extending human lives and unrealistic hopes for physical immortality bolstered by a flourishing anti-aging industry [5]. Attempts to masquerade ageing is successful to a certain extent ,but biological ageing will continue despite all such efforts, and every mortal has to face the ultimate reality of life. We have to appreciate the finitude of all living individuals.

Concepts of thanatology are not an easy topic to teach. The teaching faculty must be aware of the student’s vulnerabilities. When they engage actively in the study of a death process, the student can go through the same emotional turbulence as the dying. It will be difficult for them to acknowledge, address and cope effectively, hence it can negatively affect their self-growth. If the student has a family member who is in the process of dying, or the student has already in a grieving process, these negative impacts become worse. If the student’s family support system is weak, or he or she is a victim of substance abuse or depression, teaching and learning Thanatology will become truly a burden on them. While tutoring the students, the counselling needs of the students as outlined by Leviton [24] should be identified- Concern over past death or impending death of a loved one, Suicidal thinking and Preoccupation with fears of personal death. A death educator has to be competent enough to intervene as an interpersonal therapist and crisis counsellor, with sound knowledge on the topic. But the faculty cannot be omnipotent to deal with all the issues related to Death education. There must be good and healthier peer group support for them as well.

Lack of proper course in death education is a distressing one, as the individuals involved in the care of the dying patient will be falling into a state of helplessness and fear [24]. Death education since 1960s embraced humanistic perspective. Educators tried to balance training for practical skills with attention to personal understanding and attitudes [25].

Most physicians do not know the end of life wishes of the patient and only 15% talk with patient [26] though the physician’s communication with terminally ill cancer patients improved tremendously with a shift from withholding the truth to truth-disclosure [27] in recent times. Stepwise protocols for truth disclosure are available for ready use by physicians, e.g., breaks protocol [28]. Delivery of truth disclosure in a deadpan manner will not happen if they are trained in dealing with the death and dying. Death and dying are fearful topic for people of all ages, especially older population. By introducing natural talks on death, propagating advance medical directives in a wider manner, alleviation of symptoms can remove worries of the dying to a certain extent [5].

Death is a cultural event and societies as well as individuals reveal themselves in their treatment of death (29) Individual cultural contexts are especially important in dealing with death [30], and these differences are very well seen in multicultural societies of urban population. Different indigenous communities should be brought into the area of death research [31]. A cultural difference in various societies about the attitudes and behaviours towards death is a matter of concern for designing a universally acceptable curriculum for death education. It is important to help the students change their ethnocentric orientation and construct to death to a more global view of how culture and death are intertwined [32]. Standard didactic approach involving lectures, demonstrations, audio-visual presentations, or experiential approach with active participation of the learners can be attempted to impart death education. A combined approach is a better one.

The author identified few formal educational programmes that are relevant in the domain of death education. They are listed below with a study/URL on the respective course:

1. ACE (Advocating for Clinical Excellence: Transdisciplinary Palliative Care Education)-an innovative National Cancer Institutefunded transdisciplinary training for psycho-oncology professionals [33].

2. ELNEC (End of Life Nursing Education Consortium) ,administered through a partnership between the American Association of Colleges of Nursing (AACN) and City of Hope (Duarte, CA), achieved a significant milestone of training more than a million nurses in 2020 [34].

3. EPEC (Education in Palliative and End of Life Care) Program curriculum offers a path to develop fundamental palliative care skills in communication, ethical decision making, psychosocial considerations, and symptom management [35]. It has adaptations include EPEC for Veterans, EPEC Paediatrics and EPEC Neurology and has been successfully training health care professionals with a vision to access quality palliative and end of life care to all patients who need it.

4. ADEC (Association for Death Education and Counselling) -This international professional organisation offers a wide range of courses in Thanatology including Certification, Fellowship and Professional development courses. Death education, care of dying, grief counselling and meaningful research in Thanatology is being conducted [36].

5. University of Maryland-Death, dying and mourning: Ageing and applied Thanatology certificate program- This course will help to procure practical skills needed to provide proper care to those dealing with dying, death, and grief. Advanced and practical training can enhance individuals’ comfort level, competence, and confidence in both professional and personal contexts, claims the University. This is a twelve credit – four course- certificate program [37].

6. Kings Western University Canada: The University offers a wide range of educational programmes in Thanatology - Certificate, undergraduate and post graduate levels. The curriculum includes overview of bereavement and grief, ethical issues, palliative care, suicide, children and death, spiritual and philosophical issues, change and transition, popular culture, grief and trauma, and diversity and social justice [38].

Apart from those mentioned, many Universities and colleges facilitate formal learning on death and related issues. These educational programmes are being accepted worldwide. When medicine takes priority over everything, a doctor or nurse who ‘fails’ to address the illness and dying with a positive outcome will be viewed as a failure, and the entire process of death in dignity become overshadowed by desperation based and futile treatment. A well trained professional will not succumb to such vulnerability. And for a medical professional, this goal is consistent with the Hippocratic Oath.

1. (2009) Britannica Encyclopedia.
2. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray C J (2006) Lancet 367:1747-1757.

        

3. C Silva A, P de Oliveira Ribeiro N, R de Mello Schier A, Arias-Carrión O, Paes F, et al.(2014) CNS Neurol Disord 13:930-936.

          

4. Feifel H (1977) Death Education 1:5-14.

        

5. Wass H. (2004) Death Stud 28:289-308.

         

6. Florence ES (1990) Nursing Education in Thanatology, New York.

     

7. Doyle Derek (1991) Death studies 15:95-103.

        

8. Rabow MW, Hardie GE, Fair JM, McPhee SJ (2000) Jama 283:771-778.

        

9. Dickinson GE, Mermann AC (1996) J Assoc Am Med Coll 71:1348-1349.

          

10. Saunders C (2000) Patient Educ Couns 41:7-13.

         

11. Illene Noppe Cupit (2007) D Balk Handbook of Thanatology, New York, USA.

         

12. Golub S, Reznikoff M (1971) Nurs Res 20:503-508.

         

13. Rodríguez PHA, Miguel V (2020) Compare: A J Int Comp Educ 52:37-55.

     

14. Corr CA, Corr D M, Doka KJ (2018). Cengage learning: Brooks/Cole Publishing company.

    Cross Ref

15. King J, Hayslip Jr B (2002) Omega J Death Dying 44:37-56.

Indexed at          

16. Knott J Eugene (1979) Dying: Facing the facts, Washington Hemisphere.

    Cross Ref

17. Leviton D (1977) Death education 1:41-56.

Indexed at          

18. Jackson M, Colwell J (2002) Jessica Kingsley Publishers, United Kingdom.

    Cross Ref

19. Watson K (2018) Health Soc Care Cha 6:239-240.

     

20. Cupit IN (2013) Handbook of Thanatology, New York.

    Cross Ref

21. Gilbert K R, Murray CI (2007) Handbook of thanatology, New York, USA.

     

22. Elias N (2001) Bloomsbury Publishing, New York, USA.

    Cross Ref

23. Leviton D (1975) Omega J Death and Dying 6:183-191.

          

24. Wagner BM (1964) Am J Nurs 64:128-31.

          

25. Quint Benoliel J (1982) DC Hemisphere, Washington.

    Cross Ref

26. Connors A F, Dawson N V, Desbiens N A, Fulkerson W J, Goldman L, et al. (1995) Jama 274:1591-1598.

          

27. Klenow DJ, Youngs GA (1987) Death Stud 11:263-277.

          

28. Narayanan V, Bista B, Koshy C (2010) J Palliat Care 16:61-65.

          

29. James J Farrell (1982) Death Edu 6:105-123.

          

30. Donald P Irish, Kathleen F Lundquist, Vivien J Nelson (1993)

     

31. Kastenbaum RJ (1992) The Psychology of the Death. Springer, New York, USA.
32. Shatz MA (2002) Death Stud 26:425-430.

          

33. Otis Green S, Ferrell B, Spolum M (2009).  J Cancer Educ 24:120-126.

     

34. Kurz Jane, Hayes Evelyn (2006) Int J Nurs Educ.

          

35. Robinson K, Sutton S, Gunten C F V, Ferris FD, Molodyko N et al. (2004) J Palliat Med 7:637-645.

          

36. David K. Meagher, David E. Balk (2013) .