OMEGA--Journal of Death and Dying

This bioethics analysis of trapped civilians in the World Trade Center (WTC) on September 11, 2001, is based on a review of materials in the public domain. Death and dying experiences are divided into three major groups: sudden death, of which there was virtually no suffering or foreknowledge; deaths in which there was a maximum of 102 minutes of suffering; and death by falling or jumping, in which an autonomous decision may have been exercised as a palliative approach. A content analysis of publicly available records of this event reveals many types of end-of-life decisions were being made within the 102-minute time frame from aircraft impact to collapse. Many WTC occupants experienced intensified suffering directly consequent to unprepared emergency dispatchers and inaccurate instructions. Truthtelling and appropriate end-of-life dialogues could have reduced loss of life, suffering, and led to qualitatively improved dying experiences.

The Barratt Impulsiveness Scale-11 (BIS-11) is an important tool for measuring impulsivity in suicide research. This study aimed to assess psychometric characteristics of Chinese version of BIS-11 in suicides and controls of rural China. Data of 200 pairs of suicide cases and living controls were collected by psychological autopsy method. The Cronbach's alpha coefficients of BIS-11 were 0.936 for suicides, and 0.892 for living controls. Convergent validity analysis demonstrated a significantly positive correlation between the scores of BIS-11 with the scores of Beck Hopelessness Scale and Trait Anxiety Inventory. Confirmatory factor analyses indicated that the BIS-11 structure was basically suitable in rural China. With its high reliability, few items in BIS-11 may need a modification in order to further improve the construct validity of this instrument for suicide research in rural China.

After the Reformation, English clergymen debated the efficacy of funeral eulogies. Some believed they flattered the deceased and might be seen as prayers for the dead. Because the bereaved wanted to hear about the goodness of their beloved, most preachers gave eulogies, some in a generalized form for Godly imitation, not expressing the deceased's individuality. Samuel Hieron, a Puritan preacher, refused to give eulogies. In two that were printed, he used Biblical texts lauding the lives of Paul and Dorcas, making it possible for the grief-stricken to believe he was comparing the deceased to them. In the third, he used a text about a Worldling, angering the deceased's daughters, who believed he claimed their father had died a wicked man. Hieron prepared the sermon for publication to deny their charges but died before it appeared. His experience indicates parishioners expected to participate in decisions about how funeral services were conducted.

Obituaries from the New York Times are examined at three points to illuminate changing conceptions of death. The findings are twofold. Changes in the obituary demonstrate how the locus of social control over death has shifted from nature and God, to medicine and most recently to the individual. Additionally, it is shown that descriptions of biophysical aspects of the dying process are marginalized over time and that there is more frequent use of language that emphasizes death-resistant themes in the most recent obituaries. This finding exemplifies the observation of increasing claims to authority over mortality by individuals in recent decades.

From the magnificent to the mundane to the sublime, grave inscriptions serve as remembrances of the dead and provide concrete evidence of the thoughts and values of the day. In this study, 1,214 grave inscriptions (N = 1,214) dated 1900 to 2009 were examined for evidence of secularization and changes in attitude toward death. Using set criteria, the researchers categorized grave inscriptions in terms of language used (sacred/secular) and acceptance of death (acceptance/other). Binary logistic regression models revealed significantly more use of sacred language and significantly less acceptance of death over the past 110 years. Findings from these analyses suggest that: (a) secularization may not be as pervasive as thought, particularly with respect to death; and (b) as death has become increasingly medicalized and marginalized, society has grown less accepting of the finitude of life. These findings are further discussed in light of the continued evolution of death memorials.

The three pieces in this section introduce the Festschrift celebrating the works and influence of Omega: Journal of Death and Dying's founding editor, Robert Kastenbaum. Robert Fulton, an early Associate Editor of the Journal begins with some personal reflections on Kastenbaum. Klass and Doka then describe the nature of the Festschrift. A closing coda by Robert Kastenbaum's wife, Beatrice Kastenbaum, reminds us of the person behind the work.

This study explores the socio-cultural perception of death among Turkish people. For this reason, 210 published lament epics written by Turkish folk singers across all of Turkey concerning deaths between 1955 and 1975 were selected for analysis. These epics were published on single pages and were sold. The statistical analysis based on detailed content analysis was done at the univariate, bivariate, and multivariate levels. The results of the study provide a full picture of perception of cases of death in Turkish society. These results show Turkish society is especially sensitive to cases of death at young age and to the murdered. Further, a clear perception of the working of fate is encountered in deaths resulting from disaster and accidents; but the desire for vengeance is recorded in those laments concerning martyrs and the murdered. The statistical data show that most commonly cited reasons for death after road accidents, were a consequence of relationships with the opposite sex and from a sense of honor.

This study examined the distinctly gendered experiences of young widowers. Using qualitative longitudinal data from the 1960's Harvard Bereavement Study, we evaluated the interview transcripts of 19 widowers (median age = 38) who had been interviewed 3 weeks, 8 weeks, 13 months, and 2-4 years after the wife's death. Our findings indicate that the off-time spousal loss ruptured the ontological security that marriage provided and created two types of difficult situations for the widowers. Coping with deep sadness and grief, the men divulged their unspoken dependency on their marriage and on their late wife. They also struggled as single fathers, especially if they tried to singlehandedly care for their children. Becoming an off-time widower in the 1960s compelled the men to reclaim their masculine identity. Men's identity-rebuilding strategies involved promptly returning to work, and many men began dating and repartnering to recoup the normalcy of being married.

Newspaper obituaries are important mourning rituals that announce the deaths of individuals and share their life stories with others. Obituaries also provide insight into the societal values and attitudes of the day. The purpose of this study was to investigate whether factors such as gender and age were related to age-inaccuracy in obituary photographs and whether the level of age-inaccurate photographs has increased over time. Obituary photographs were analyzed from The Cleveland Plain Dealer for the years 1967, 1977, 1987, and 1997 (N = 400). Results indicated that obituary photographs of women (p < 0.001) and of older adults (p < 0.001) were much more likely to be age-inaccurate. Analysis also revealed a consistent upward trend in age-inaccurate photographs over time (p < 0.05). The findings from this study indicate that society's bias toward youthful appearance has persisted and grown over time, particularly in the case of older women.

Regression models of cross-national differences in social and economic predictors of per capita alcohol consumption and gender-specific cirrhosis mortality rates are developed for 13 European countries, first using 1970-1984 (period 1) data and then replicating with 1995-2007 (period 2) data. Regression analysis finds that stronger alcohol control policy laws and income inequality are highly significant predictors of consumption in both periods. Further, results show that alcohol consumption is a significant predictor of male mortality rates in both periods, while it is significant only in the second period for female cirrhosis mortality rates. Psychological well-being is a significant predictor for male and female cirrhosis mortality rates in both periods.

Attitudes about “the right to die” were studied among high school and college students at three recent points in time. A general item about the right to decide between life and death, and a specific one about that right for the terminally ill were accepted by more than half the students; both were more accepted than an item rejecting life after death. All three items were related to beliefs about religion, abortion, teenage birth control, and the worth of current ideas. The “right to die” items were positively correlated in all groups; the more conservative the students, the likelier they were to disagree with them. Agreement was related to belief in self-determination in moral/social matters. The item rejecting life after death was generally unrelated to the “right to die” items and to liberalism-conservatism, but its acceptance was greater among the more dogmatic college students, and among those derogating ideas and people. Possible reasons for the combined personality and time period effects were discussed; they suggest a potential backlash after more legislation such as the California law is passed, as is currently happening in the area of abortion.

This study examines the seventy-five suicide cases Dr. Jack Kevorkian acknowledged assisting during the period between 1990-1997. Although these cases represent a range of regional and occupational backgrounds, a significant majority are women. Most of these individuals had a disabling, chronic, nonterminal-stage illness. In five female cases, the medical examiner found no evidence of disease whatsoever. About half of the women were between the ages of forty-one and sixty, and another third were older adults. Men's conditions were somewhat less likely than women's to be chronic and nonterminal-stage. The main reasons for the hastened death mentioned by both the person and their significant others were having disabilities, being in pain, and fear of being a burden. The predominance of women among Kevorkian's assisted suicides contrasts with national trends in suicide mortality, where men are a clear majority. It is possible that individuals whose death was hastened by Kevorkian are not representative of physician-assisted suicide cases around the country, because of Kevorkian's unique approach. Alternatively, the preponderance of women among Kevorkian's assisted suicides may represent a real phenomenon. One possibility is that, in the United States, assisted suicide is particularly acceptable for women. Individual, interpersonal, social, economic, and cultural factors encouraging assisted suicide in women are examined.

Social and behavioral scientists have increasingly attended to the contexts and motivational dynamics underlying parricidal events. These efforts notwithstanding, most research has focused on adolescent or adult male offender populations. One largely neglected area of study is that of adult female offender parricide. The present study utilizes archival records to examine the contexts and sources of conflict that gave rise to adult female offender parricides in the late 19th century. Three general themes emerged, representing the primary contexts behind adult female offender parricide: (1) abuse and neglect; (2) instrumental, financially-motivated killings; and (3) expressive killings, often during the course of arguments. Each of these contexts is explored.

This study examines all documented information regarding the final days and death of Edgar Allan Poe (1809-1849), in an attempt to determine the most likely cause of death of the American poet, short story writer, and literary critic. Information was gathered from letters, newspaper accounts, and magazine articles written during the period after Poe's death, and also from biographies and medical journal articles written up until the present. A chronology of Poe's final days was constructed, and this was used to form a differential diagnosis of possible causes of death. Death theories over the last 160 years were analyzed using this information. This analysis, along with a review of Poe's past medical history, would seem to support an alcohol-related cause of death.

Obituaries do not only announce the death of a significant other but also provide insights into how a society deals with death according to the norms governing the rituals of individuals within that society. This study aimed at investigating possible differences between German and Dutch obituaries, specifically in terms of visual and textual elements, information about the deceased, and funeral ceremony-related information. Data used to address the research questions were the contents of 240 German and 240 Dutch obituaries published in 10 different newspapers (6 in Germany, 4 in The Netherlands). Results of this study show that statistically significant differences between German and Dutch obituaries exist. While German obituaries use illustrations more than Dutch ones, Dutch obituaries provide more information, in general, than their German counterparts. The types of deceased-related information on German and Dutch obituaries also vary significantly. Moreover, Dutch obituaries provide more funeral ceremony-related information than German obituaries.

Prior studies conducted in the area of Advance Care Directive document completion in African Americans have primarily targeted the elderly who are either institutionalized in skilled nursing facilities or are members of faith communities. Few studies have been done concerning barriers to Advance Care Directive document completion that include non-elderly African Americans. The purpose of this study was to identify the common barriers to advance care directive document completion across generations of African Americans ages 25-84. Using convenience sampling among various Baptist denominations of the African-American faith community of Buncombe County, North Carolina, 40 individuals ranging in age from 25-84 participated in multiple focus group sessions. Findings revealed participants shared three common barriers: 1) surrogate decision-making, 2) lack of education concerning advance care directive discussions and completion, and 3) fear and denial. Also revealed were barriers that varied across generations: 1) fatalism, 2) mistrust of the health care system, 3) spirituality, and 4) economics.

Initial support is presented for a new scale that assesses one's life ownership orientation or the extent to which one believes that God, the individual, or society has the power to control and govern one's life. Life Ownership Orientation Questionnaire (LOOQ) scores demonstrated higher predictive validity with regard to attitudes toward abortion, suicide, doctor-assisted suicide, and capital punishment than did measures of religiosity and political liberalism-conservatism.

This article explores the grief of Japanese parents after abortion and the ritual by which the grief is resolved. The ritual is Mizuko Kuyo. Mizuko means “child of the water.” Kuyo is a Buddhist offering. In a ritual drama played out by Jizo, the bodhisattva who suffers for others, the parents' pain and the child's pain are connected, and in that connection the pain of each is resolved. The child is made part of the community and does not become a spirit bringing harm to the family. The parents can fulfill their obligation to care for the child and transform the sense of kumon, sickness unto death, into a realization Buddhism's first noble truth, that all life is suffering. The subtext of the article is the search for an adequate method and language by which cross-cultural study of grief can move forward.

In recent years, euthanasia has become a topic of increased concern. Predictions were made regarding the relationship between attitudes toward euthanasia and various other attitudinal components of death and dying. Information on these attitudes was obtained from fixed-schedule interviews gathered from 331 respondents in Lubbock, Texas. It was found that a favorable attitude toward euthanasia coincided with (1) belief in an afterlife, (2) a less favorable attitude toward euthanasia if relatives make the decision, and (3) younger respondents. Additionally, belief in an afterlife was related to preference for death by natural causes. Other predictions were not verified. The implications of these results are discussed.

Hospice of Sacred Heart, an agency of PeaceHealth Oregon, experienced a dramatic increase in its census beginning in 2007. The spiritual care team noticed the number of referrals was decreasing while the census was increasing. A quality improvement initiative was conducted, including a staff survey, an education program about spirituality and the role of chaplains on interdisciplinary teams in the hospice setting, and an audit of the chaplain's daily allocation of time. These actions resulted in an increase in the use of spiritual care services by patients and staff and the addition of two full-time, benefited chaplain positions.

While there is ample evidence to support the need for hospice and palliative care services for African Americans, only 8% of patients who utilize those services are from African-American communities. The underutilization of end-of-life and palliative care can be attributed to several barriers to service access including incompatibility between hospice philosophy and African-American religious, spiritual, and cultural beliefs; health care disparities; distrust of the medical establishment; physician influence; financial disincentives, and hospice admission criteria. Suggestions for dismantling barriers to care access include developing culturally competent professionals in the health and human services, expanding the philosophy of hospice to include spiritual advisors from client communities, and funding national initiatives to promote improved access to health care at all stages in the life cycle of members of all underserved communities.

In this short article, the authors describe their attempt to do suicide-prevention with a patient that ultimately died as the result of a physician-assisted suicide. Autopsy revealed no sign of physical disease but the patient's letters indicate a preoccupation with independence as the definition of life, and conviction that people who lose independence are no longer alive. I am not stressed, oppressed, or depressed. I don't have Alzheimer's and am not terminally ill, but I am 82 years old and I want to die.

Health professionals, researchers, and philosophers have debated extensively about suicide. Some believe suicides result from mental pathology, whereas others argue that individuals are capable of rational suicide. This debate is particularly poignant within illness communities, where individuals may be suffering from chronic and incurable conditions. This article engages with these issues by presenting the accounts of 20 individuals with Huntington disease (HD), a fatal degenerative condition, and 10 informal caregivers (e.g., spouses). Suicide is a leading cause of death amongst people with HD, with an incidence rate many times higher than the general population. In contrast to the majority of the academic literature on HD suicidality, study participants did not connect suicide with mental pathology. Instead, they perceived suicide as a response to the realities of living with HD, such as prolonged physiological degeneration and the need for long-term intensive health care. These findings are subsequently discussed in relation to the rational-pathological suicide binary.

Psychologists, social workers, and spiritual care professionals report inadequate preparation to maximize their effectiveness in advocating for institutional reform to meet oncology patients' diverse bio-psychosocial-spiritual and cultural needs. This article provides an overview of the ACE Project, a National Cancer Institute, 5 year, R25-funded transdisciplinary palliative care education program designed to enhance the advocacy and leadership skills of 301 competitively selected psycho-oncology professionals. ACE Project participants identified an institutional goal, refined their goals during the course and received mentorship and support throughout the subsequent year. Participants were invited to return to a Reunion Conference in year five to report on their activities, network, and share the results of their change efforts. A subset of 28 ACE Project participants contributed to this OMEGA special issue. Participants' goals primarily focused on strategies to improve clinical care through program development and improvements in palliative care education within their institutions. The results of this transdisciplinary leadership skills-building program for psycho-oncology professionals affirm the feasibility and perceived need for the program. See the ACE Project website (http://www.cityofhope.org/education/health-professional-education/nursing-education/ACE-project/Pages/default.aspx) for additional program information.

From the moment her interest in terminal care was awakened, Cicely Saunders was alert to the international dimensions of the subject. Her first patient in the late 1940s was an emigré Polish Jew dying alone and in isolation in a busy London hospital. Her letters from the 1950s onwards show an unquenchable thirst for new knowledge and a span of contacts and communications that was global in its reach. By the early 1960s, she was making fact-finding visits to the United States and Europe. Even before it opened to patients, St Christopher's Hospice was a beacon of inspiration to like-minded colleagues from many countries, eager to see how the model of practice was being operationalized and--more important still--how it could be adapted and modified in other settings. In the later years of her life, Cicely Saunders remained in contact with colleagues all over the world. She wrote introductions to numerous textbooks and collections; recorded interviews that were broadcast at international conferences; harnessed her name and energies to major efforts to promote palliative care globally; and, to the very end, served as a source of inspiration to palliative care activists, policy makers, educators, and researchers. As this special issue of the journal demonstrates so eloquently, that legacy lives on.

Advance Directives were created by Congress in an attempt to better serve the needs of patients in long term care and acute care settings. The Patient Self-Determination Act of 1990 was an excellent concept to further patient rights, but the Act did not present necessary guidelines to insure uniform implementation. Healthcare providers were given flexibility in designing and implementing policies and procedures to operationalize the Act. However, key Professionals are not actively participating in the implementation. Examined are patients' perspectives and ideas on how professionals should be actively involved in meeting the consumers needs, wants, and desires. A model on how to effectively implement the Patient Self-Determination Act of 1990 is discussed.

A transdisciplinary team is an essential component of palliative and end-of-life care. This article will demonstrate how to develop a transdisciplinary approach to palliative care, incorporating nursing, social work, spiritual care, and pharmacy in an acute care setting. Objectives included: identifying transdisciplinary roles contributing to care in the acute care setting; defining the palliative care model and mission; identifying patient/family and institutional needs; and developing palliative care tools. Methods included a needs assessment and the development of assessment tools, an education program, community resources, and a patient satisfaction survey. After 1 year of implementation, the transdisciplinary palliative care team consisted of seven palliative care physicians, two social workers, two chaplains, a pharmacist, and End-of-Life Nursing Consortium (ELNEC) trained nurses. Palomar Health now has a palliative care service with a consistent process for transdisciplinary communication and intervention for adult critical care patients with advanced, chronic illness.

An intervention was conducted, aimed at providing residents in internal medicine with communication skills to address end-of-life issues with patients. Residents participated in two 1-hour educational sessions designed to teach a communication protocol, enhance listening skills, and to provide practice in effective communication in a safe, small-group format. An anonymous on-line survey assessed the effectiveness of the intervention. Twenty-five residents completed the intervention. There was a trend toward increased comfort level in addressing end-of-life issues among residents who completed the intervention, versus a comparison group. Residents who completed the intervention reported that using the words "death" and "dying" with patients and families was an important teaching point.

Death is the end of life. But Muslims believe death is an event between two lives, not an absolute cessation of life. Thus religiosity may influence Muslims differently about death. To explore the impact of religious perception, thus religiosity, a cross-sectional, descriptive, analytic and correlational study was conducted on 150 Muslims. Self-declared healthy Muslims equally from both sexes (N = 150, Age range--20 to 50 years, Minimum education--Bachelor) were selected by stratified sampling and randomly under each stratum. Subjects, divided in five levels of religiosity, were assessed and scored for the presence of maladjustment symptoms and stage of adjustment with death. ANOVA and correlation coefficient was applied on the sets of data collected. All statistical tests were done at the level of 95% confidence (P < 0.05). Final results were higher than the table values used for ANOVA and correlation coefficient yielded P values of < 0.05, < 0.01, and < 0.001. Religiosity as a criterion of Muslims influenced the quality of adjustment with death positively. So we hypothesized that religiosity may help Muslims adjust to death.

This research sought to investigate the role of social networks in coping and adjustment to spousal bereavement. A total of 198 Xhosa-speaking participants, drawn from the rural areas of the Eastern Cape Province, South Africa, took part in the study. Quantitative data analyses revealed significant correlations between perceived social support on Social Support Appraisals scale and the anxiety scores on the Beck Depression Inventory-Second Edition and the problem-solving coping strategy scale on the Coping Strategy Indicator. Regression analyses revealed that depression contributed to increased social support appraisals, while anxiety was a significant negative predictor of the participants' experience of perceived social support. The authors highlight the need for bereavement intervention programs in the rural areas to be geared toward psycho-educating the conjugally bereaved individuals, within the socio-cultural framework, to continuously evaluate their support structures and strengthen ties with social networks that render support, instrumental assistance, and advice in times of need.

This article presents findings from a study on the impact of a child's death on parents. We explored the prominence and adaptiveness of parents' continuing bonds expressions, psychological adjustment, and grief reactions. A qualitative case study methodology was used to describe six cases. Participants were classified into two groups based on scores on the Inventory of Complicated Grief. Commonalities in themes on the Continuing Bonds Interview and projective drawings were assessed. Those in the Non-Complicated Grief Group reported internalization of positive qualities and identification with the deceased child as a role model, whereas participants in the Complicated Grief Group did not report these experiences. In addition, the drawings of those in the Non-Complicated Grief Group were evaluated as more adaptive than those in the Complicated Grief Group.

The article sheds light on the way the author's scientific views and endeavors in the field of dying, death, and bereavement over 40 years in Germany have been influenced by the work of Robert Kastenbaum. Reconstructing the passage of time, the early years (i.e., the second half of the 1970s), a middle period (i.e., the 1980s and 1990s), and the later years (i.e., from the turn of the century to the present) are outlined. In an anecdotic fashion, two personal encounters with R. Kastenbaum are reported. The article concludes with showing\consensus and dissention in various respects and finally recounts the author's admiration for this outstanding scholar.

Bereaved adolescents (N = 90) who had experienced relatively common death losses (e.g., grandparent, friend) completed the Texas Revised Inventory of Grief and the Emotional Closeness Scale and Continuum. Results indicated that present grief was significantly higher for friend than for grandparent death loss. A MANOVA revealed that those in the high closeness group reported significantly higher mean scores on past and present grief than those in the low closeness group. Finally, in a hierarchal multiple regression, after demographic variables were entered (e.g., age, present at death), emotional closeness added significant variance to the prediction of past and present grief. This research contributes to the understanding of grief intensity following adolescents' most common death losses and highlights the importance of counselors' intentionally and directly assessing bereaved adolescents' perceived emotional closeness to the deceased as part of grief-related counseling.

This qualitative study is the follow-up to a quantitative controlled study which showed a decrease in childhood traumatic grief and posttraumatic stress disorder symptoms in parentally bereaved children participating in a bereavement camp. The purpose of this study was to identify the healing components of this camp model. Semi-structured interviews with 19 children and 13 parents/guardians were conducted 3 to 9 months after participation in the bereavement camp. Therapeutic Interventions and Traditional Camp Activities emerged as themes. The themes are discussed in relation to previous research as are limitations of the study and the implications for theory, practice, and future research.

Possible relationships between bereavement and religiosity to death anxiety levels of adolescents were investigated. Scales measuring religiosity, bereavement, and death anxiety were incorporated into one questionnaire. Two hundred and twenty-six adolescents between the ages of 11 and 18 participated in the study based in urban and rural private schools within Manitoba. Females exhibited significantly higher death anxiety levels than did males; differences between the death anxiety levels of adolescents having a no-previous-death-experience death and those who had experienced a familial death were not significant; while religiosity levels were significantly higher for students attending religion-based schools, the relationships between measurements of religiosity and death anxiety were weak. Grief due to bereavement was the major factor in determining death anxiety for the adolescent.

Effective evidence-based intervention for traumatic bereavement is one of the current major research issues in the field of Post Traumatic Stress Disorder (PTSD) in children and adolescents. The "Writing for Recovery" group intervention is a new treatment approach developed by the Children and War Foundation for traumatized and bereaved children and adolescents after disasters. The purpose of this project was an empirical examination of this intervention with 12- to 18-year-old war bereaved Afghani refugees. Eighty-eight war bereaved Afghani refugees were screened using the Traumatic Grief Inventory for Children (TGIC). From those with the highest total score, 61 were randomly assigned to either an experimental (n = 29) or control group (n = 32). The experimental group received six sessions of group training on 3 consecutive days in their school. The difference of TGIC scores between the experimental group in pretest and posttest was significant (p = 0.001). Results of analysis of covariance also showed a significant effect of Writing for Recovery on the experimental group (p < 0.001). It is concluded that "Writing for Recovery" is an effective group intervention for bereaved children and adolescents after disasters.

Using the Posttraumatic Growth Inventory, we examined posttraumatic growth in a sample of 50 adolescents and young adults who had experienced parental death in childhood or adolescence. Longitudinal relations were examined between baseline measures of contextual and intraindividual factors and scores on the posttraumatic growth subscales (i.e., New Possibilities, Relating to Others, Personal Strengths, Spiritual Changes, and Appreciation of Life) six years later. Controlling for time since death, threat appraisals, active coping, avoidant coping, seeking support from parents or guardians, seeking support from other adults, internalizing problems, and externalizing problems were significant predictors of posttraumatic growth. The implications of these findings for research and clinical practice are discussed.

This study analyzes the difficulties that poor parents faced when they lost an adult child to AIDS in Togo. The death of a child is believed to be more distressful to parents compared to the death of a spouse. Evidence also suggests that parental grief is more lasting and may be the most complicated form of grief. Furthermore, the roles played by the deceased child in the lives of the parents also affect the parental grieving process. For instance, in low income regions where parents tend to be socio-economically challenged and where filial obligations are culturally expected, losing an adult child who provided material and financial assistance to parents will be more disastrous. Four kinds of difficulties were identified: financial and social difficulty, psychological difficulty, caregiving difficulty, and disclosure difficulty. The socioeconomic status of the parents made these issues all the more taxing, as respondents were grieving not only the loss of their children to AIDS but also the loss of financial providers. Policy implications of the findings are discussed.

This article focuses upon whether 422 randomly selected older adults believe that Dr. Jack Kevorkian should or should not be prosecuted. The study was conducted by Ball State University's Department of Sociology in the Lynd's classic community setting of "Middletown," a.k.a. Muncie, Indiana. The findings indicate that a majority of the respondents do not support prosecuting Kevorkian and also feel that the terminally-ill have the right to end their own lives. Of eight variables included in the initial analysis, four were found to explain most of the variance in attitudes toward prosecuting Dr. Kevorkian. Those variable are: attitudes on taking one's life to end suffering, political liberalism-conservatism, education and frequency of church attendance (R = 0.5331; R2 = 0.2842). Those who favor the right to take one's life to end suffering, who see themselves as politically liberal, who are more educated and who attend church less frequently, tend to oppose prosecution. A multivariate path analysis examines interrelationships between the eight variables previously mentioned.

Examination of the theory base for bereavement and loss is currently just beginning for adults with intellectual disabilities (ID). Yet, as life spans increase for individuals with ID, these adults experience more and more loss and bereavement events. Practitioners, especially grief counselors, are finding it increasingly critical for them to understand best practice principles for working with bereaved adults with ID in their daily work. Practitioners also are asked to guide families and care providers regarding grief and death education. This article provides counselors and other professionals with a review of existing bereavement intervention research for adults with ID. Practice recommendations are made on three levels: informal support; formal intervention; and community education.

Complicated Grief (CG) is a prolonged, impairing mental health condition affecting about 7% of the bereaved. CG may be especially prevalent in older adults. Though evidence-based treatments for CG have been developed, little is known about support-seeking in older adults with CG. This study used the descriptive phenomenological approach to explore the CG support-seeking process. In-depth interviews were conducted with 8 CG-positive older adults who had completed participation in a randomized clinical trial of CG treatment. Five primary themes arose: observing that grief was causing a great deal of distress and impairment; grief not meeting expectations of what grief "should be"; an important influence of social relationships on support-seeking; lack of effectiveness of grief support groups and/or care from mental health professionals prior to study enrollment; and strong reactions to the label of CG. Themes may hep inform efforts to engage older adults with CG in effective care.

Michigan public opinion on Doctor Assisted Suicide (DAS) was assessed in January 1997 (N=603). Asked if they would consider DAS for themselves, two-thirds would if being kept alive by machine or were experiencing chronic pain; one-half would if they experienced a loss in mobility or independence, became a burden to others, or were diagnosed with a terminal disease; and one-third would if they were incontinent or going to a nursing home. A series of demographic and attitudinal comparisons were made for support for the concept of DAS and as a hypothetical consideration for oneself. The highest support for the concept of DAS was found among the following: men eighteen to twenty-four years old, some college education, $35-60,000/year income, Caucasian, Democrat, liberal, Protestant, and frequent church attendee. The highest self-consideration of DAS was found among the following: men, fifty to fifty-five years old, post-graduate education, $35-60,000/year income, Caucasian, Democrat, liberal, Protestant, and infrequent church attendee.

The death of a loved one requires many adults to make decisions about a variety of details regarding funeral arrangements. Based upon data collected from 348 adults (M age = 34.21) who had attended the funeral of a loved one within the last year, a scale consisting of 50 items regarding the difficulties each had experienced with regard to events prior to, during, and after the funeral, was developed. Cronbach's Alpha coefficient for this measure of difficulty was .96. Principal components analysis of these data indicated that difficulty in coping with funerals could be understood in light of six factors explaining 56% of the common variance among relationships between items: 1) protocol/mechanics of the funeral; 2) general personal and interpersonal difficulties related to the death/funeral; 3) trust in the funeral industry; 4) concerns regarding the cemetery; 5) issues pertaining to grief; and 6) post-funeral personal responsibilities. With regard to both overall difficulty and the above six factors, older adults experienced fewer difficulties, as did those who more actively participated in funeral rituals. In contrast, those who reported more personal and bereavement-related distress experienced more difficulties. Findings of the current study have value both in identifying persons for whom funerals may undermine bereavement adjustment and in identifying appropriate intervention and aftercare services for such individuals.

The current study had two primary goals, to determine whether: 1) self-rated mental and physical health, pain, and experience with health problems were predictors of elderly adults' attitudes toward death; and 2) death attitudes predict end-of-life medical treatment concerns. Participants were 109 adults, 65 years of age or older (M=78.74 years), recruited from the local community. Regression analysis indicated that poorer perceived physical health predicted a greater likelihood of viewing death as an escape, and poorer perceived mental health predicted a greater fear of death. Viewing death as an escape and fearing death predicted end-of-life medical treatment concerns; a greater endorsement of either attitude predicted more concern. Possible explanations for the links between perceived health, attitudes toward death, and concern about end-of-life issues are suggested.

There is growing concern regarding the proper implementation of advance directives. A workable model for physicians to use with patients along with appropriate guidelines is discussed in the context of the physician-patient relationship. Examined are variables involved in the establishment of guidelines for use by the physician in the office practice and inpatient settings. Key management and clinical factors for initiating and implementing an advance directive are identified for the practicing physician. Responsibility for the initiation of education regarding the advanced directive is discussed from the patient perspective. Effective use of advance directives with patients requires that a physician have an adequate knowledge base to appropriately guide the patient throughout the treatment process, and that any efforts are coordinated with other healthcare providers.

Advance directives are a means whereby competent individuals can guide treatment decisions, and in many cases their death, at a future time when they may be rendered incompetent of doing so. This article first examines the differences between nursing home residents who choose to use advance directives and those that do not. Second, the differences between nursing homes who choose to use advance directives and those that do not are examined. Also, advance directives are not investigated as homogeneous constructs, rather they are divided into residents with a do-not-resuscitate (DNR) status and those with other advance directives (i.e., do-not-hospitalize, living wills, and feeding restrictions). A multinomial logistic regression model with data representing 60,366 nursing home residents in ten states is used. Thirteen factors are significantly associated with a DNR status, whereas eleven factors are significantly associated with other advance directives. In both cases these significant factors include both...

Various forms of Advance Directives (Living Wills; Durable Powers of Attorney) are available that allow individuals to leave instructions about the conditions under which they would and would not want to be allowed to die. These Directives are often worded too vaguely to be helpful. A series of specific questions is described giving more precision to Advance Directives. All competent adults should consider and answer these questions; attending to this matter while one is able may prevent future suffering for both oneself and one's loved ones.

Research has demonstrated that limited dialogue in end-of-life (EOL) care can negatively impact decision-making and place of death. Furthermore, when vulnerable populations are faced with EOL cancer care, they experience issues resulting from previous gaps in services attributed to sociocultural and economic issues that influence EOL care. These conditions place an additional burden on disadvantaged populations which can cause distress, especially as disparate conditions continue to persist. Little is known about Latinos' psychosocial concerns that lead to distress in EOL care. The objective of this study is to explore Latinas' experiences with life-limiting cancer conditions to identify the EOL care concerns that impact their dying experience. This study used a phenomenological approach to explore the EOL care concerns of 24 Latinas receiving treatment for metastatic cancers in a public sector healthcare system in Los Angeles, California. In-depth interviews were recorded and transcribed, and qualitative analysis was performed using Atlas.ti software.

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) is being revised. A proposed revision hotly debated is to remove what is known as the exclusionary criterion and allow clinicians to diagnose a person with a major depressive episode within the early days and weeks following a death. The Executive Committee of the Association for Death Education and Counseling (ADEC) commissioned its Scientific Advisory Committee (SAC) to examine the debate over removing the exclusionary criterion and provide a written report. The DSM-IV-TR classifies bereavement as a clinical condition that is not a mental disorder. The exclusionary criterion states that within the first 2 months of the onset of bereavement a person should not be diagnosed as having major depression unless certain symptoms not characteristic of a normal grief reaction are present. We note these symptoms when discussing the exclusionary criterion. In the report we identify the features that comprise the exclusionary criterion, examine reasons (including research conclusions and clinical concerns) given for retaining and for eliminating the exclusionary criterion, offer extensive comments from experienced licensed clinicians about the issues involved, discuss diagnostic and treatment implications, and offer specific recommendations for ADEC to implement.

A large community-based oncology practice developed a pilot project to enhance staff and patient awareness of the benefits of palliative care, advance care planning, and earlier intervention with patients with advancing disease. The results were ongoing implementation of palliative care conferences at all sites, greater numbers of referral to hospice, lessened chemotherapy given in the last 2 weeks of life, and the hiring of two social workers as a result of needs identified. Staff reported greater satisfaction with interprofessional communication.