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In this qualitative study, we explored how Chinese rural elders narrate death-related issues and death preparation. Adopting a phenomenological approach, we interviewed 14 participants regarding the particular actions they employ to prepare for death. The findings revealed a death preparation system for rural Chinese elders that is instrumental in how they converse about death, wish for a good death, make objects and symbols, and anticipate an afterlife as a worshiped ancestor rather than a wandering ghost. Family and family honour provide the context for death preparation. We discuss implications and the need for the death preparation education of younger generations.
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Death Studies
ISSN: 0748-1187 (Print) 1091-7683 (Online) Journal homepage:
Death preparation of Chinese rural elders
Yanping Liu & Gertina J. van Schalkwyk
To cite this article: Yanping Liu & Gertina J. van Schalkwyk (2018): Death preparation of Chinese
rural elders, Death Studies, DOI: 10.1080/07481187.2018.1458760
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Accepted author version posted online: 14
May 2018.
Published online: 14 Sep 2018.
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Death preparation of Chinese rural elders
Yanping Liu
and Gertina J. van Schalkwyk
Department of Psychology, University of Macau, Taipa, Macau, China;
Department of Psychology, Honghe University, Mengzi, China
In this qualitative study, we explored how Chinese rural elders narrate death-related issues
and death preparation. Adopting a phenomenological approach, we interviewed 14 partici-
pants regarding the particular actions they employ to prepare for death. The findings
revealed a death preparation system for rural Chinese elders that is instrumental in how
they converse about death, wish for a good death, make objects and symbols, and antici-
pate an afterlife as a worshiped ancestor rather than a wandering ghost. Family and family
honor provide the context for death preparation. We discuss implications and the need for
the death preparation education of younger generations.
Death is a natural and integral part of life (Wong,
Reker, & Gesser, 1994), and approaching death is
something most people have to deal with toward the
end of life. Encountering death could be unpleasant
and anxiety-provoking (Hui & Coleman, 2013;
Neimeyer, Wittkowski, & Moser, 2004). On the other
hand, a proactive way to deal with end-of-life issues
and death-related stress may be to prepare for death
(Chan, Chan, Tin, Chow, & Chan, 2007; Yalom, 1980,
2008). Studies addressing the end-of-life complexities
and death-related issues experienced by rural elders
are few and most research focuses on advance care
planning for the elderly in urban Chinese settings
such as Hong Kong (Chan et al., 2007; Ming-lin &
Lang, 1998; Mjelde-Mossey & Chan, 2007) and
Singapore (Chan & Yau, 2010). Other research investi-
gating end-of-life issues focuses on mental health and
coping strategies for left-behind elders in rural China
(e.g., Cui, Wang, & Zhang, 2011), and research
regarding death preparation among Chinese elders in
deep rural areas of the south has thus far
been neglected.
China is officially a country of many peoples and
ethnicities, and nearly three quarters of the ever-
expanding Chinese elderly live in rural areas (Li, Chi,
& Xu, 2013). A great number of elders are left behind
in rural areas by the younger generations migrating to
urban areas (Norstrand & Xu, 2012) and without the
resources to cope with end-of-life issues and death-
related stress. Many of these rural elders are less edu-
cated, have fewer financial and social resources, and
seemingly do not or cannot engage in advance care
planning such as buying life insurance, signing wills,
finding care facilities for fragile elders, or securing a
burial place (Chan et al., 2007). It is thus problematic
to transfer research from urban settings in China (e.g.,
Hong Kong, Shanghai) to understand how elderly in
rural areas prepare for death (Chan & Yau, 2010). In
this study, we aim to describe how rural Chinese eld-
ers, who are in the latter phase of life and living in a
village in the deep south of China, think and talk
about death, and the actions they take to prepare for
death. Adopting a phenomenological approach, we
intend to give voice to the grandparents and elders in
a rural village with the central question: How do
rural Chinese elders talk about death and make sense
of life through death preparation?
Death preparation
Death preparation refers broadly to the actions one
takes to arrive at a calm acceptance of ones own mor-
tality. In this study, death preparation refers to the
actions one takes to prearrange the end of ones life-
span (Chan & Yau, 2010). It includes thinking and
talking about death, deciding to die well, and engaging
in activities that will ensure good dying. Thinking and
talking about death makes us aware of both living and
CONTACT Gertina J. van Schalkwyk Department of Psychology, University of Macau, Avenida da Universidade, Taipa, Macao
(SAR), China.
ß2018 Taylor & Francis
dying, a process of making sense of life because
though the physicality of death destroys us, the idea
of death saves us(Yalom, 1980, p. 40). We may pon-
der how to spend the remaining period between the
present and the moment of dying, so that we live well
enough to die well. Death preparation can happen for
everyone at any time of life when he/she reflects upon
his/her life and/or the end-of-life issues of a family
member (Chan et al., 2007; Chan & Yau, 2010). The
inclination to prepare for death, however, might be
stronger for those who are closer to the end of
their lifespan.
Haj and Antoine (2016) view death preparation as
one of the functions of reminiscence and aimed at
deriving a sense of continuity and meaning in ones
life that also contributes to a sense of closure and
calmness in older adults(p. 520). In more traditional
and rural Chinese communities, there is no real fear
of death but talking about death is considered by
some as a social taboo (Chan & Yau, 2010). Rather,
Chinese people generally avoid talking about death
because they believe conversations about death could
bring negative consequences like evoking evil spirits
(Chow & Chan, 2006). On the other hand, Chinese
people who believe in the afterlife and value ancestral
worship speak highly of the dying process, funerary
rituals, and ceremonies that represent safe transition
into heaven and the afterlife (Mjelde-Mossey & Chan,
2007; Webster, Bohlmeijer, & Westerhof, 2010).
A good death, although perceived differently from
culture to culture and from the perspectives of the
dying person, broadly refers to dying nobly or to be
prepared to meet ones death without fear (Howarth
& Leaman, 2003 ; Yalom, 2008), and to a slow and
lingering end of life as fitting the expectations of a
continued connection between the living and the
dying. Hart, Sainsbury and Short (1998) refer to a
good death as the kind of death that takes place as a
public event, for example, in the dying persons home
where family members, friends, co-workers, and even
some members of the community have an opportunity
to surround and support the dying person. Taking
action to prepare for death is to carry out the decision
to die well and ensure transition to the afterlife. It
includes activities such as purchasing life insurance,
writing a will, planning for ones property distribution,
the funeral, and so on (Chan & Yau, 2010; Pinquart &
Sorensen, 2002; Robbins, 1991).
For those near dying, advance care planning is a
further step making arrangements about how one
wants to be treated (Mullick, Martin, & Sallnow 2013)
and to die well. Mak and Clinton (1999) claimed that
family members are instrumental in assisting with
end-of-life issues and socio-emotional care in later life.
Additionally, when talking openly about death prepa-
rations as is the situation with advance care planning,
family members or caregivers learn about the expecta-
tions of the dying person and the preferred burial rit-
uals. They can also prepare to perform the necessary
rituals for the dying person as per his or her wishes
(Mullick et al., 2013). Preparing for death is not only
helpful for the dying person to gain a sense of integ-
rity and certainty about the uncertainty of dying and
the afterlife (Firestone & Catlett, 2009), it is also bene-
ficial for family members (Carr, 2003; Chan, Tse, &
Chan, 2006). Death preparation also helps with family
membersgrieving process and, contrary to a sudden
or accidental death, reduces stress that might compli-
cate the grief reactions (Neimeyer & Sands, 2011).
Thus, death preparation is an ongoing process that
could start early in life (Gielen, 1997), and family
members and caregivers benefit from death prepar-
ation when they relieve the dying person from further
stress by accepting the impending death.
Framing of the study
Studies pertaining to death and dying, as well as death
preparation, provide useful but limited understanding
of the phenomenon in rural areas (Chan et al., 2007;
Chan & Yau, 2010; Ming-lin & Lang, 1998; Mjelde-
Mossey & Chan, 2007). Although some studies address
death-related attitudes and coping with end-of-life
stress in rural China (e.g., Chen, Jin, & Guo, 2006;
Norstrand & Xu, 2012), research regarding death
preparation among Chinese elders in deep rural areas
of the south is uncommon. In particular, there is little
attention regarding how rural Chinese elderly talk
about their own impending death and how they pre-
pare for dying well. In Western societies, research on
death and dying has progressed markedly from earlier
stage theories. Adopting a holistic approach, Corr
(1992) acknowledged individual differences, rejected
broad generalizations, and emphasized four dimen-
sions or tasks that the dying person must face. The
taskwork approach involves recognition of bodily
needs, psychological security, interpersonal attach-
ments, and spiritual energy and hope. Kastenbaum
(2012) expanded on Corrs approach, proposing a way
for understanding society and peoples roles within
that society when faced with death, their own death,
or that of a loved one.
Kastenbaum (2012) proclaimed that death is a com-
plex system integrating the interpersonal, socio-phys-
ical, and symbolic network through which an
individuals relationship to mortality is mediated by
society(p. 102). The death system, with its five ele-
ments (i.e., people, places, times, objects, and symbols)
and seven functions (i.e., warnings and predictions,
preventing death, caring for the dying, disposing of
the dead, making social consolidation after death,
making sense of death, and killing), explains who and
what is involved in the context of death, as well as
attitudes regulating peoples behavior related to death.
This sociocultural and systemic view of the death sys-
tem paved the way for us to frame the current study
regarding the elements and functions of death prepar-
ation among Chinese rural elders, and how these rural
elders make sense of life through their reminiscing
and actions preparing for death.
The study of the death preparation of Chinese rural
elders is a part of a larger project on life storytelling
and reminiscing, which received ethical approval from
the University of Macau. To the best of our know-
ledge, the larger project is a first inquiry regarding the
role of reminiscence in the identity construction of
rural Chinese elders, and we opted for narrative
inquiry (McAdams, 2008; Riessman, 2007) and a phe-
nomenological methodology (Moustakas, 1994).
Narrative inquiry and phenomenology allowed us to
interview elders living in a small village in southern
China, giving voice to a minority group often
neglected in ageing research. For the purpose of this
study, we extracted parts of the interviews from the
larger study, focusing on the central question of how
rural Chinese people talked about death and made
sense of life through death preparation. Only the sec-
tions specifically related to death and their actions to
ensure a good death were used for analysis and
reported here.
We recruited participants through purposive snowball
sampling, identifying several key participants and ask-
ing them to introduce us to other participants
(Merriam, 2009). In terms of the recruiting criteria,
we made sure participants identified as both a rural
resident with registration in the local community or
hukou (i.e., the Chinese system for categorizing citi-
zens according to their socioeconomic status and liv-
ing arrangements) and an elder, which was
determined, according to village tradition, by someone
already having a grandchild. Local people do not have
retirement; they believe becoming a grandparent
marks the beginning of old age, no matter the
persons actual age. Older adults with diagnosed phys-
ical and/or psychological disabilities (e.g., age-related
hearing loss, dementia syndromes) were not included
as these disorders were considered barriers for
In the current study, we interviewed 14 volunteer
elders recruited according to above criteria. They were
between 47 and 85 years of age, with only three par-
ticipants younger than 60 years of age (M¼69.14,
SD ¼11.04; N
¼7). Nine elders reported declin-
ing health but none had any clinical diagnosis for
mental health disorders, and all participants were able
to talk freely and respond to the interview questions.
Seven participants had no prior formal education,
while the other participants had 1 to 5 years of
schooling. Thirteen participants were married and one
was widowed. Living arrangements varied with seven
participants living with their spouses separate from
other family members, and the other seven living in
intergenerational family settings. Most local people in
the village are peasants working in farmlands. Some of
the younger residents migrate to cities for work but
return home regularly, especially during traditional
festivals and holidays. Residents of the village are
related either by blood or through daily living, work-
ing, and leisure interactions.
Data collection
The first author carried out one-on-one interviews
with each of the 14 elders, between January and July
2016. All interviews were conducted in the local dia-
lect and audio-recorded with verbal consent from the
participants. Participants were free to choose where
they wanted to be interviewed, and the venues varied
from their living rooms, a private room in their house,
porches of their houses, or a room in the house of a
neighbor. The interviews varied in time from 42 to
108 min (M¼79).
Only one interview per participant was conducted.
The interview was semi-structured using an adapted
version of the Life Story Interview schedule (LSI;
McAdams, 2008) as guideline. Each interview pro-
gressed following three steps: (1) introducing the aim
of the interview and related issues (e.g., confidential-
ity), (2) listening to the participants autobiographical
telling, and (3) probing certain unclear dimensions in
his/her storytelling. Most participants were eager to
tell their stories without interruption. In cases where a
participant did not know what to say or shared very
little about his/her life, or when a participants telling
became repetitive or without new information,
prompts were used to maintain the focus on life
storytelling and death-related narrating. Example ques-
tions were as follows: what are your thoughts and per-
ceptions about death; have you made any preparations
for your own death; what preparations have you made
for your own death; and why do you consider these
preparations important?
Throughout the data collection process, we consid-
ered the participantsbenefit and protection from
potential risks. Before starting the interview, each par-
ticipant was informed about the study purpose, audio-
recording of the conversation with the interviewer,
and confidentiality of personal information. Since
most participants had limited or no education and
could not read or write, or were reticent writing his/
her name because of earlier socialpolitical persecu-
tion experiences during the Cultural Revolution
period, consent was recorded verbally. Refreshments
were provided after the interview as a token of appre-
ciation, and participants did not receive any monetary
compensation. No coercion took place and all partici-
pants were free to stop the storytelling at any point in
time without any consequence.
Data analysis
Since we assumed death preparation to be contextual-
ized in the participantseveryday lives, we gathered
the participantslife stories and then extracted only
their death-related narratives for further analysis. Data
analysis involved a continuous process via concurrent
interviewing, transcribing, memo-writing, member
checking, peer review, and researchersreflection. We
examined each narrative regarding the follow-
ing questions:
Does the rural elderly talk about death and death
preparation, and if they do, how do they talk
about it?
Does the rural elderly care about a good death, and
if they do, why?
How do the rural elderly we interviewed make
sense of life by preparing for death, and what
actions do they take to prepare?
We used thematic analysis to identify and analyze
patterns within the dataset following the six phases
proposed by Braun and Clarke (2006). In this regard,
we familiarized ourselves with the data, first tran-
scribed the audio-recorded interviews into text format,
and translated the Chinese version into English for
the benefit of the second author who is not familiar
with Chinese writing. Although some of the finer
nuances of expression could be lost in the translation
process, we enlisted the assistance of bilingual col-
leagues (i.e., doctoral students and staff in the depart-
ment) to review the transcripts for accuracy and
capturing the intent of participants. Next, we inde-
pendently coded the textual data generating initial
codes and searching for themes in response to the
above questions. Reviewing the themes several times,
and defining and naming the themes provided a pre-
liminary model for describing the ways in which rural
Chinese elderly made sense of death through death
preparation. In cases where our analysis of the textual
data diverted, we discussed alternatives and included
only those themes for which consensus could be
reached, and in response to the central question for
this study. Establishing trustworthiness and credibility
was a continuous process involving member checking
and maintaining an audit trail. After the initial analy-
ses, the first author conducted member checking with
key participants in the community to confirm the ten-
tative interpretations and discussed the findings with
local people.
Findings and discussion
The analysis yielded four themes death conversation,
good dying, death preparation as instrumental, and
death preparation as taking action representing the
death preparation mechanisms employed by elders liv-
ing in a rural community in southern China.
Maintaining the narrative approach, the findings and
discussion are integrated and where relevant, partic-
ipantsown voices are included. We conclude the dis-
cussion with a preliminary model of death preparation
for elderly Chinese (Figure 1).
Death conversation
The participants we interviewed talked freely and
openly about death as a natural and inevitable part of
life. They used a grass-peoplemetaphor to describe
Preparaon as
Context: Family
Good Dying
Aerlife &
Making Objects
& Symbols
Figure 1. Rural death preparation system.
their living and dying: just as grass grows and withers
seasonally, people do what they must do naturally at
certain phases of life (e.g., getting married, having
children) and then they die like the grass in winter.
Participants were comfortable telling stories about
accidental near-death experiences, their own impend-
ing death, death of community members, and suicide
attempts of their parents, children, siblings, or neigh-
bors. For example, Mrs. O. (59 y/o) described her
fathers suicide attempts during the Land Reform
period (during the 1950s), her parentsdying and the
funeral proceedings, her own near-death experiences
in a hospital when she was 28 years of age, as well as
her recent actions preparing for death by making cof-
fins for herself and her husband. For the most part,
participants talked about death as natural and some-
thing for which one should be prepared in advance,
whether to accept the inevitability of death or to take
actions ensuring a good death.
Participants also talked about death as part of ones
destiny. Everyone has that day [the end of life]
This is what destiny is about. How long a person can
live is decided(Mrs. O.), and of heaven/hell and an
afterlife. Heaven for them is the ultimate destination
and not something to be decided by the individual
her/himself. Mrs. N. (76 y/o) commented: When the
moment comes, just go with it. I will go whenever the
heaven wants me,and Mrs. P. (72 y/o) added: When
heaven wants me it [dying] is just like falling asleep
there is nothing [I could do].A natural death is good
for ones afterlife and thus good for obtaining the liv-
ing generationsworship. Participants generally
seemed to believe that a natural death is preferable to
one where death is brought on by accidents, failed
surgery, or suicide. Such interference or unnatural
death could negatively affect a person and perhaps
even result in him/her becoming a wandering ghost in
hell. Mr. G. (71 y/o) particularly mentioned: If a per-
son is not meant to die but he poisons himself to
death, there would be no road in the hell for him to
walk the hell will not even accept him.
Culture and religion provided context and content
for talking about death and the wish for a good death
through properly preparing in advance. The partic-
ipantsnarratives about death were contextualized in
their rural surroundings, and they presented unique
expressions (e.g., the grass-peoplemetaphor), rela-
tively unique to rural people working in farmlands.
The finding that rural elders openly talking about
death is consistent with research reports of urban
Chinese populations (Chan & Yau, 2010; Ming-lin &
Lang, 1998), although contrary to the general view-
point that conversations about death and death
preparation are a social taboo in traditional Chinese
societies (see Chow & Chan, 2006; Mjelde-Mossey &
Chan, 2007). Mjelde-Mossey and Chan (2007) specu-
lated that contemporary Chinese people living in
urban areas are less likely following traditional values
affirming the inconsistence between empirical findings
and folk beliefs. However, in our interviews with the
rural elderly in the village, it seemed that conversing
about end-of-life issues such as death and death prep-
aration was common practice. For them, talking about
death was natural and taking action to prepare for a
good death expected not only by the individual but
also by the community more generally.
Good dying
The participants we interviewed conversed at length
about prearrangement for good dying and pursuing
traditional practices when on ones death bed. Good
dying rituals for the participants include having their
children gathered around the death bed, specifically
the oldest son who has to perform the first ritual
when his parent dies. The sons are also the ones
expected to put the body of his deceased parent into
the coffin, cater for a big funeral ceremony, and bear-
ing the coffin to the ancestral cemetery. Overall, the
participants in our study believe that having children
particularly having a son and grandsons was the
most important achievement in life and vital for hav-
ing a good death and good afterlife. Mr. B. (80 y/o)
said, What is the purpose of living in the world? A
human must leave successors, like grass leaving roots.
Such a belief is shared commonly, even among the
elders who feel their children will not support them
when they are really old.
Having no sons and grandsons could be humiliat-
ing for the elders in the village both while they are
alive as well as when approaching death. For them,
having no sons and grandsons precludes one from
dying well and from entering the afterlife.
The ancestors always said, humans have to have sons
for posterity, like leaving grass roots Having
children is the continuation of Chinese society if
he has no son, the continuation is broken the
ancestors would say having no sons and grandsons
means he is not qualified to be buried in the ancestral
graves. (Mr. G., 71 y/o)
Raising a good son to host a beautiful funeral
ceremony is like having a good father to host a
beautiful wedding ceremony. (Mrs. M., 71 y/o)
Mrs. O. (59 y/o) mentioned a funeral ritual valued
by local people, namely having someone catch the
dying persons last breath.It seems that for ones
death to be a good one, the children would gather
around the death bed and when noticing the moment
when his parent expresses her/his last breath, the old-
est son in the family should lift up the deceased par-
ent while other siblings change the parents clothes. It
is good to catch the parents last breath at the right
moment, so that the body is still warm and soft, and
it is easy to put on the burial shrouds. Thus, being
prepared and having sons, especially the oldest one,
around when one dies is important for elders living in
this rural village.
Such a son preference for participants comes from
the traditional belief that only sons can continue the
familys care and lineage because daughters leave their
family of origin to care for in-laws upon marriage (Sit,
2017). Chinese ancestor worship, according to Yick
and Gupta (2002),entails praying for the lineage on
the males line of descent(p. 33). In the village, once
daughters become wives, they are treated as relative
outsidersto the original family, living with another
family that can be very far away from their parents.
Sons, in contrast, married or not, are supposed to live
with or near their parents, take care of the parents
when they are really old, and conduct the funeral rit-
uals. Son preference for a good death is a shared trad-
ition in other Asian cultures, too. B
elanger (2002)
found rural Vietnamese attributed special spiritual val-
ues to sons who are not only perceived as the ones
who carry on the family line, but also the ones to per-
form the cultural rituals, cater for parentsfuneral cer-
emonies, and celebrate the death anniversaries.
Mjelde-Mossey and Chan (2007) pose that death is
the turning point into the afterlife, while death prepar-
ation is a way to construct a good afterlife. In the
afterlife, one becomes an ancestor who is believed to
play an important role in blessing the family and con-
necting generations of families (Yick & Gupta, 2002).
It is believed that if the ancestor has a good afterlife
and is worshiped well, they can bless the family with
good luck and avoiding misfortune. Chinese elders in
the rural south also want to resolve unfinished busi-
ness before the death (Chan et al., 2006) and forgive
past transgressions against them. Reminiscing, the par-
ticipants in our study told stories about the challenges
they faced in the past, interpersonal conflicts, and
their childrens unfilial attitudes and behaviors.
Nonetheless, when talking about their own impending
death, many participants said: There is nothing you
could do [then],and they pursued ways of forgive
and make peace with past sufferings as part of their
death preparation and constructing a good death.
The notion of family support as integral to a good
death for the Chinese rural elderly aligning with
reports from urban Chinese elders (Chan & Yau,
2010), Vietnamese rural residents (B
elanger, 2002), and
elders from Western cultures (e.g., Carr, 2003; Mullick
et al., 2013). However, the spiritual value of the oldest
son seems particularly important for Asian cultures
elanger, 2002) as a means to ensure good dying and
gain entrance to a good afterlife. The preference for
oldest son at ones death bed is usually cultivated at a
young age through daily interactions with ageing
people in the community. With the rural-to-urban
migration of the younger generation in recent years, it
is possible that younger generations have lost the
opportunity to learn about these expectations of their
ageing parents, leaving the elderly with uncertainty
about how to prepare appropriately for death.
Death preparation as instrumental
For the elderly we interviewed, death preparation is
instrumental for a good death and afterlife. It is also a
way to sacrifice oneself in order to save the next gen-
erations from difficulties. In her death preparation,
Mrs. M. (71 y/o) declined the possibility of going to
hospital given her ill health considering the cost it
might imply to her sons and wanting to spare them
the expense: He [her husband] said I should go to
the hospital. I think it would not make much differ-
ence. I am already 71 years old. Do I want to recover?
That is not possible. And the sons often give me
money when they come back home but I just do not
want it.Mrs. M. refused the prospects of a longer
life, sacrificing her own well-being in order not to
burden her sons.
Other participants are seemingly prepared to take
their own lives (e.g., suicide), partly to avoid humili-
ation for the children in the village and partly as pay-
back to their adult childrens lack of caregiving. In the
village, it is supposed that the adult sons family will
take care of his elderly parents when they can no lon-
ger live by or care for themselves. However, sensing
the helplessness of being alone in his final days, Mr.
D. (68 y/o) considered preparing for death taking mat-
ters in his own hands committing suicide as a way to
end his life. He also wants to punish his unfilial son
and daughter-in-law, saying:
We [his wife and him] cannot rely on the
children when I cannot cook for myself, eat by
myself or when I am really ill when I am very near
death. I will make a small bottle of pesticide, and
carry it with me all the time. When I am really
suffering and hungry, with no one to look me, I will
just lift up the bottle and drink it and go to sleep in
the bed and go to see the king of hell. Others in
the village will judge our daughter-in-law for treating
us badly I want a social judgement.
In the Chinese rural tradition, suicide is one type
of planned death sacrificing heroically for the good of
others or minimizing the miseries of a poor living and
unfilial children (see Liu & Wang, 2013). Whereas
Mrs. N. (76 y/o) claimed that When that happens
[dying], no matter how I suffer, I will bear it. I do not
consider other ways because it [committing suicide]
influences the family,and is willing to sacrifice her-
self to avoid her sons humiliation, Mr. D. seemed to
consider suicide as a way of punishing his family
members who, because of the suicide, will lose face in
the community. Mr. Ds intentions appeared to fit Liu
and Wangs(2013) theory regarding the four types of
suicidal motivation among Chinese rural residents: for
ones own good (e.g., to terminate suffering), for the
good of others (e.g., to substitute sons severe punish-
ment in villages), for retaliation (e.g., to punish unfilial
son or daughter-in-law), and due to a sense of help-
lessness. Unlike urban elders who prepare for death
anticipating a good afterlife and becoming a wor-
shiped ancestor (Chan & Yau, 2010; Mjelde-Mossey &
Chan, 2007), some rural elders seem willing to give up
this idealized future arranging for their own death
through suicide and becoming a wandering ghost
(Mr. G. regarding dying an unnatural death).
Death preparation as taking action
As anticipated in this study, taking action and making
objects and symbols associated with death and dying
was important and necessary for the participants in
our study. It [the coffin] should be prepared. You
may see he is quite healthy now but who knows, some-
day, suddenly, right he may die. If you have to
hurry up at that time making the coffin, people will
laugh at you.(Mrs. M., 71 y/o); and These things
[death related] should be prepared. Prepare it early.
Whenever it comes, it is ok …” (Mrs. O., 59 y/o).
Instead of relying on others (their children/family or
the community), they chose to take action to ensure a
good death, and preparations were described as start-
ing early when the individual is still healthy and able
to make the objects and symbols that should ensure
their transition to the afterlife (i.e., coffin and shrouds
for burial clothing). Mrs. O. (59 y/o) and her husband
made their coffins years ago prior to her husbands
illness, while Mr. and Mrs. B. (respectively, 79 and
80 y/o) made their coffins twice because a fire
destroyed the ones made in their early sixties. Mrs. B.
commented that If the coffins were made, [her
son] wont need to worry about it he would know
it is prepared,while Mr. F. (76 y/o) said: When you
are really old and the heaven wants you, people could
just put you [your body] into it It is good to put
the body into a coffin [already made].
The elderly seemingly derived pride knowing they
have prepared for their own death-related rituals and
could lessen their childrens burdens at the time of
death. Mrs. M. (71 y/o) proudly talked about having
done most of the preparations for her husbands and
her own funerals, because when death comes, the
sons and daughters would not know what to do and
where to begin. They are too young to know these
things The wood for making the coffin was
brought by myself. I made it. I paid for it without
using the childrens money.Other participants fear
that if they do not make preparations, their unfilial
children could further ruin the familys reputation by
not doing what is expected.
Death-related objects and symbols are culturally
determined and dependent on the availability of things
such as life insurance, signing wills, or finding burial
sites (Chan & Yau, 2010; Kastenbaum, 2012; Pinquart
& Sorensen, 2002; Robbins, 1991). For the rural elders,
death preparation depends on the making coffins and
shrouds by oneself, having sons and grandsons present
at ones death bed, or knowing the means to commit
suicide. Rural elders also take action distributing per-
sonal possessions early. Mrs. M. (71 y/o) asked her
grandson to take something to his home because: In
my mind, I am thinking leaving something to the next
generation will be a reminder of me.Ensuring inter-
generational links through early distribution of mater-
ial goods is yet another way to prepare for a good
death and generate a feeling of continuation with the
next generation following death. Intergenerational
connectivity gives a sense that one will be remembered
in a positive way, leaving legacies for the next gener-
ation (Firestone & Catlett, 2009), and having a good
death and appropriate funeral ceremony. Death prep-
aration is pertinent to establish good connections with
future generations and for being worshiped well in the
afterlife (Yick & Gupta, 2002).
A preliminary model of death preparation
Our preliminary death preparation model explicates
how rural elders perceive death as instrumental in
their conversations about death, describe their wish
for dying well, take action making objects and sym-
bols, and aspire for honor and worship in the afterlife
(Figure 1), and this is similar to Kastenbaums(2012)
death system. Family and the family honor provide
the context for death preparation and this is not dif-
ferent from elders elsewhere (B
elanger, 2002; Carr,
2003; Chan & Yau, 2010; Pinquart & Sorensen, 2002).
However, for the rural Chinese participants we inter-
viewed, death preparation is also instrumental in pro-
tecting the family from humiliation and dishonor, for
entering the afterlife, and becoming a worshiped
ancestor who died well. Dying well is preferred to be
becoming a wandering ghost who committed suicide.
Good dying seems to be a universal theme in death
preparation across cultures where people take action
to minimize death anxiety (B
elanger, 2002; Chan &
Yau, 2010; Mullick et al., 2013).
Conversing about death and making death-related
objects and symbols are implied in the death system
proposed by Kastenbaum (2012) and others (e.g.,
Chan & Yau, 2010; Pinquart & Sorensen, 2002;
Robbins, 1991) and were instrumental to the rural eld-
ersdeath preparation system. As a function of remin-
iscence (Haj & Antoine, 2016; Webster et al., 2010),
conversing about death and death preparation also
promotes death acceptance. Contrary to common
belief, the elders we interviewed eagerly talked about
death and their preparations for a good death, also
contemplating the prospects of speaking with their
children when they around. The distress of having
supposedly unfilial children or children who live too
far away to take proper care of their ageing parents
emerged in conversations of contemplating suicide
an unnatural death that could deprive them from an
afterlife and a relatively unique form of death prepar-
ation for rural Chinese elders (Liu & Wang, 2013).
We found that rural Chinese elders living in a village
in southern China openly talked about death and
actively prepared for their own death. The participants
believed that death is natural, destined to happen and
a transition to an afterlife. Preparing for death is a
process integrated with family memberscooperation,
especially the oldest son, and planning for a good
death is important to become a worshiped ancestor in
afterlife. Chinese rural elders commit to death prepar-
ation somewhat differently from their urban counter-
parts. Yet, the preparing for death in order to feel
peace about their living, death and afterlife, and by
balancing personal and family-based benefits is shared
in both rural and urban areas. The model we propose
is an attempt to systematically capture death prepar-
ation as instrumental to the elements involved in rural
eldersend-of-life experiences. Chinese elders, both
rural and urban, prepare for death. They share com-
monalities talking about death and aspiring for having
a good death, although they differ in the actual proc-
esses of preparing for death.
There are some limitations in the study worth men-
tioning. The findings of this study should be under-
stood in the local context of the community within
which we conducted the narrative data collection it
is locally specific and not necessarily applicable to all
rural Chinese elders. Nonetheless, although not the
aim of a qualitative study to generalize, we present the
rich descriptions about death preparation adding to a
greater understanding of how the socialcultural
scripts in rural communities could inform the context
and content of death preparation. Additionally, there
could be some participant-recruitment bias as we
could only collect data from the elders who were will-
ing to share their stories with us. Another challenge is
related to the transcription of local dialect and transla-
tion of the field texts. We interviewed the participants
using local dialect, transcribed the audio-taped inter-
views in Mandarin, and translated the transcripts into
English. Although we collaborated to reduce errors of
interpretation, working with translated texts always
involves the possibility of losing some of the nuanced
meanings embedded in participantscolloquial lan-
guage used during the interview.
Further research is necessary to broaden our under-
standing of the death preparation system among rural
Chinese elderly and to verify the preliminary model
proposed here. We also propose that death prepar-
ation should be taken into consideration when revi-
sing policies regarding elderly welfare. Our study
revealed that the death preparation system is of par-
ticular importance to rural elderly, and we believe that
policy revisions might be necessary explicating the
need for family members of rural elders to be edu-
cated about their parentsend-of-life needs. Social
services in rural areas should also consider provide
advanced care planning for people living away from
major cities and the primary care of family members.
Considering that the suicide rate among rural elders is
almost five times higher than that for urban elders (Li,
Xiao, & Xiao, 2009), further investigation into how
rural elders perceive suicide as preferable to dying
without family (or sons) to support one in the final
days is necessary. These elders might need other forms
of assistance so that they could at least have the
option of choosing a good death instead. Finally, we
urge caregivers, social workers, elderly centers, and
health institutions to note the importance of death
preparation for the elderly in deep rural areas and to
be more easily accessible where the need is highest.
The authors wish to thank the participants for their gener-
osity sharing their stories.
The study was funded by Universidade de Macau. This
work was supported by the University of Macau [grant
number MYRG2015-00191-FSS] and awarded to Gertina J.
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... The research aim of six studies was to explore Chinese healthcare professionals' experience of and/or attitudes to caring for dying and death (Dong et al., 2016, Gu et al., 2016, Pan et al., 2021, Wang et al., 2004, Yang et al., 2019, Zheng et al., 2015. Nine studies focused on understandings of death and dying from patients' and relatives' perspectives (Gu et al., 2007, Huang et al., 2015, Huang et al., 2018, Ivo et al., 2012, Keimig, 2020, Liu and van Schalkwyk, 2019, Tang, 2019, Zhang et al., 2013. Two studies explored the components of the 'good death' by focusing on end-of-life decision-making processes (Gu et al., 2016. ...
... Seven studies used qualitative research designs, whereas six studies used semi-structured interviews (Dong et al., 2016, Pan et al., 2021, Zheng et al., 2015, Liu and van Schalkwyk, 2019, Zhang et al., 2013 and one was an ethnographic field study, using both observations and semi-structured interviews (Keimig, 2020). Eleven studies used quantitative designs, whereas two studies were based on standardised questionnaires (Yang et al., 2019, Huang et al., 2015, five used self-designed questionnaires (Wang et al., 2004, Gu et al., 2007, Ivo et al., 2012, Tang, 2019, Cui et al., 2011, two used empirical material from medical records (Gu et al., 2016, Deng et al., 2014, one used a non-randomised controlled design (Chen et al., 2020), and one used selected game cards . ...
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Background Considering older adults are getting closer to the end-of-life and face death more directly. Attitudes to death not only affect the physical and mental health of older adults, but also affect their acceptance of hospice care, even the quality of death. This study aims to explore the status, influencing factors of attitudes toward death and demands of death education among the community-dwelling older adults in southwestern China. Methods A cross-sectional survey was adopted to investigate 683 community-dwelling older adults in Chongqing, China. Non-parametric test and multiple linear regression analysis was used to explore the influencing factors of different attitudes toward death of older adults in community. Results The multiple linear regression models showed that different dimensions of death attitudes were affected by one or more factors including number of diseases, discussion about life and death, marital status, and average income per month. And community-dwelling older adults have high level demand for death education. Conclusions Under the taboo culture of death in China, this study is one of the few studies on the attitudes toward death and the demands for death education of the community-dwelling older adults. This study contributes to enrich the global death studies and provide reference for the death education for older adults.
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Filial piety has a long historical standing in Chinese communities. However, the filial piety practices of adult children at the end of a parent’s life are under-explored. This study aims to develop a measurement for filial piety representations of the adult children of Macao Chinese, whose parents are at the stage of end of life. By adopting a scale development and validation framework, a 19-item Filial Piety Representations at Parents’ End of Life Scale (FPR-EoL) was formulated based on a Dual Filial Piety Model and literature, through procedures of item identification, panel review, cognitive interviews, and pre-test. The FPR-EoL was examined on 274 individuals. Factor analysis showed four factors in the scale; respect and comfort, acceptance of death, spending final days, and disclosing bad news. The Cronbach’s alpha of FPR-EoL was 0.73, and the four factors were 0.73, 0.66, 0.58 and 0.77, respectively. Discriminant validity was examined between FPR-EoL, the Good Death Inventory (GDI) and the Filial Piety Scale (FPS). The results suggested that there were differences between the three scales. FPR-EoL is found to be a reliable, valid and novel measure of filial piety representations among Macao Chinese. It may be a potential tool to probe and achieve good death among older persons of Chinese ethnicity in clinical settings.
... Dealing with dying and death is particularly challenging for Chinese-born nurses ( Liu & van Schalkwyk, 2019 ). Previous studies have shown that Chinese nurses were not well prepared for the role in the provision of end-of-life care, or for coping with patient dying and death ( Zheng, Bloomer, Guo, & Lee, 2021 ;Zheng, Guo, Dong, & Gao, 2022 ). ...
Background: As a result of globalisation, many Chinese-born nurses choose to work outside China. They are expected to be competent in providing end-of-life care and dealing with dying and death within the new country, where cultural beliefs, attitudes, and values towards dying and death may differ from their own. It is essential to consider the influence of Chinese culture on nurses’ confidence and preparedness for end-of-life care, especially for dealing with dying and death. Purpose: To discuss Chinese perspectives on dying and death, and death education and training in mainland China, from which we propose recommendations for nurse educators, clinical mentors and researchers in Western settings on how to prepare Chinese-born nurses to care for patients at end-of-life. Discussion: Chinese-born nurses likely encounter significant cultural challenges when providing end-of-life care to dying patients in Western settings. Chinese-born nurses’ perspectives, attitudes and values toward dying and death are shaped by Chinese cultural and social beliefs, practices and expectations, which contrast with those of Western settings. Nurse educators, clinical mentors and researchers in Western settings are encouraged to support and guide Chinese-born nurses in building their cross-cultural understanding and world view to an international view of nursing; essential foundations to the provision of end-of-life care, and nurse coping with dying and death in Western settings. Conclusion: The development of death education programs and training to support Chinese-born nurses to attain their cultural competence is a priority in Western countries, to better promote these nurses’ competency in providing high-quality end-of-life care.
... In such a case, one possible buffer for the Buddhists who are mostly of Chinese ethnicity in Malaysia, is the belief in ancestral worship which helps maintain a sense of connection following death (Hsu, O'Connor & Lee, 2009). It provides a sense of peace in the afterlife because a worshipped ancestor would not become a wandering ghost (Liu & van Schalkwyk, 2019). The difficulty in letting go of someone might also be a reason why the participants mentioned that they would tend to invest a lot on health essentials that would help to prolong the lives of their loved ones, possibly due to sociocultural conditioning. ...
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The topic of death perception is often a matter related to older people. As there is a paucity of studies with the young population, insights into their views would be helpful to healthcare professionals who may be confronted by events of death and dying. This study is aimed at exploring the perception of death among young adults of different religions in a multi-cultural and multi-faith society as in Malaysia. A total of 32 participants representing the main religious groups, i.e., Islam, Christianity, Buddhism and Hinduism were recruited from the Klang Valley area of Peninsular Malaysia. Focus group discussions were undertaken with participants grouped according to their religious identifications. Five themes emerged from the data: (a) Belief in Afterlife, (b) Fear of Own Death, (c) Fear of Others’ Death, (d) Preparation towards Death and Afterlife, and (e) Way of Living. In a diverse and polarised society such as in conservative Malaysia, insights into death perceptions of different main groups of people can play a significant role in the provision of health care.
... Furthermore, anguish, fear, depression and anxiety could challenge the preservation of the dignity of the patient and family, including the care provider. Death is generally considered to be good if it is met without fear 17 and happens at the preferred place, Opinion Article such as at home 18 . Being surrounded by close family members and being able to express goodbyes 16 are also important factors. ...
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All compounded things are impermanent. All emotions are pain. All things have no inherent existence. Nirvana is beyond concepts." Buddha Sakyamuni Suffering and cause In Buddhism, suffering is the broader psychological ideas of dissatisfaction, capturing the fact that life never quite lives up to our expectations, plans, hopes, and dreams. As captured above in the four seals of Buddhism, the fundamental teachings of Buddha surround the discourse of four noble truths, which includes the truth of suffering, its origination, the truth that suffering can be eliminated, and the path to the cessation of suffering. Within the context of these four noble truths, selfish craving, aversion, greed, wrong desire, grasping, lust, and attached wanting are the root causes and conditions of suffering 1. These causes are rooted in ignorance and are inherently an integral part of human beings. Suffering such as pain, grief, misery or dissatisfaction, sickness, birth, ageing, and death are part of the samsara. Although humans aspire for continuous happiness, our behaviors are driven by ignorance, which is contradictory and results in our suffering. The idea of karma (cause-effect) is more closely related with Hinduism, Jainism, and Sikhism, and is heavily discussed in Buddhism. Karma believes that every action including behavior, speech, intent/thought (causes) continuously produce a reaction (effect) that influences the future of an individual 2. Even nonreligious people seem to believe in some sort of forces at work in the world such as "what goes around comes around". Therefore, the COVID-19 pandemic that our entire humanity is currently experiencing is also a result of karma, determined by human behaviors and intentions. As is the belief in science, the COVID-19 pandemic is non-inherent in existence, but is the result of cause-condition and effect. Many scholars consider that COVID-19 was transmitted from wild animals to humans through trading and some people believe that this pandemic could be the revenge of wild animals 3. As stated in the teachings of four noble truths, sickness causes suffering as COVID-19 does. Our cravings for pleasures (causes) which are sometimes built on the painful experience of others (such as wildlife trading) are often rooted in our ignorance. The way towards elimination of suffering is to stop cravings, become more self-aware, and realize the significance of interdependence. The emergence of new diseases like COVID-19 can be prevented if human beings introspect, inner engineer, and transform to counter an outside world which is filled with attractions and distractions that are transitory and interdependent. As nothing lasts forever, COVID-19 is also a transitory and passing thing
The purpose of this literature review was to describe older individuals' perceptions of a good death. A systematic data search of CINAHL, Medline, PsycINFO, ASSIA, and Medic databases from 2010 to 2020, supplemented with a manual search, resulted in 16 studies that met the inclusion criteria. Study quality was assessed using the JBI critical appraisal criteria. Data were analyzed by inductive content analysis. The core elements of older individuals' perceptions of a good death were a dignified moment of death, factors that enhance the desire to live, an active agency in adapting to death, and equal interpersonal relationships.
The COVID-19 pandemic revealed a need for people and communities for death preparation. Few studies have examined community-level interventions for death preparation and education. This scoping review scrutinized the relevant literature following PRISMA 2018 guidelines. Six databases were searched for articles published between 2010 and 2020. We found that cultural, socioeconomic, and individual values affected death preparation and that online courses and life-death education were effective preparation methods. Additional research is needed to identify the population-specific effectiveness of interventions. To fully investigate death preparation and education at the community level, theory-based studies employing quantitative and qualitative methods are also needed.
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Reminiscence, or the process of thinking or telling about past experience, is thought to serve social, instrumental, and integrative functions. Our paper investigated these functions in Alzheimer's disease (AD). Twenty-six participants with a clinical diagnosis of probable mild AD and 28 control older adults filled in a French adaptation of the Reminiscence Functions Scale. Eight specific functions were assessed: death preparation, identity, problem-solving, teaching/informing, conversation, boredom reduction, bitterness revival, and intimacy maintenance. Both older adults and AD participants reported reminiscence about their past to prepare themselves for the idea of their own mortality. All participants also reported reminiscence "to reduce boredom" and "for something to do". However, reminiscence for death preparation and boredom reduction was reported more by AD participants than by older adults. In all participants, the death preparation function of reminiscence was significantly correlated with depression. Individuals with AD seem to reminiscence to cope with thoughts about their own mortality. This helps them to see that they have lived a full life and can therefore accept death more calmly. Individuals with AD also seem to cope with boredom by using reminiscence, probably as a tool to fill time or simply to create ease of conversation.
Providing an overview of the myriad ways that we are touched by death and dying, both as an individual and as a member of society, this book will help readers understand our relationship with death. Kastenbaum and Moreman show how various ways that individual and societal attitudes influence both how and when we die and how we live and deal with the knowledge of death and loss. This landmark text draws on contributions from the social and behavioral sciences as well as the humanities, such as history, religion, philosophy, literature, and the arts, to provide thorough coverage of understanding death and the dying process. Death, Society, and Human Experience was originally written by Robert Kastenbaum, a renowned scholar who developed one of the world's first death education courses. Christopher Moreman, who has worked in the field of death studies for almost two decades specializing in afterlife beliefs and experiences, has updated this edition.
This chapter takes the reader on a step-by-step journey through the process of conducting a qualitative research study using research conducted with Traditional Healers (THs) in Malaysia and how they diagnose and treat cancer. Upwards of 80% of Malaysians consult traditional healers before seeing a medical doctor, resulting in late-stage diagnoses and thus higher mortality rates. However, prior to our research, little was known about the role of healers and their willingness to work with, rather than outside, the Western medical system. Within this context, the theoretical framework, the specific research problem and the research questions were identified. Next, the author discusses purposive sampling and data collection strategies, which included interviews, documents, and observations. She then presents a data analysis exhibit showing how they captured specific data from the interviews to address the research questions. Finally, the author discusses writing and publishing the results of the research.
Research studies on "good death" have increased our awareness of what is important for both terminally ill patients and bereaved family members. Nevertheless, these findings should not be considered the "norm" for every individual, and those who cannot meet the criteria of "good death" as found in these studies should not be viewed as having "bad death". Walter25 also indicated that some norms in the culture may constrain how one should grieve, thus causing "policing grief which may not be adaptive. One of the reflections of this challenge is to reject the dichotomous thinking of death into just "good" and "bad". Masson26 indicated that the terminology of "good death" failed to reflect the complex process of death and dying. He suggested that the term "good-enough death" could better explain the situation, as it emphasized the realistic context and contingency. Instead of evaluating the death simply as "good" or "bad", helping professionals may facilitate bereaved persons' consideration of their specific contexts and appreciate the "good-enough death" under the circumstances. Another reflection on "good death" is that, no matter how good the death, it is still a great loss for many bereaved persons. Thus, by no means can "good death" necessarily predict "good bereavement" in all situations. As Chan9 proposed, both "good death" and "good life" are required for achieving "good bereavement". Ensuring a "good life" of bereaved persons, like reconstructing the meaning of life after loss27 in a totally different world after the death of loved ones,28 may better facilitate the bereaved in coping with their grief. Henderson and Hayslip29 have shown that general adjustment in life can better predict the level of bereavement-related distress, whereas the reverse is not true. Thus, instead of just focusing on grief work, helping the bereaved persons to adjust to changes in daily life circumstances may be effective in bereavement intervention. Moreover, intervention focusing on ensuring "good life" can be more proactive, and may match well the pragmatic orientation of bereaved persons.21 For example, it will be of great importance if bereaved older adults can be helped to spend time more meaningfully, in order to face loneliness in old age after the death of a spouse. There is room for further research on "good death", "good life" and "good bereavement". What are the long-term effects of "good death" on the adjustment of bereaved persons? Will "good death" predict the personal growth of bereaved persons? What is "good life" as perceived by bereaved persons in different age groups? What is "good bereavement" as perceived by bereaved persons? All these research findings will probably shed much more light on our intervention, and integrating this new knowledge into our practice will be the next step forward.
The aim of this study was to investigate the efficacy of afterlife beliefs and ego integrity as two mediators of the negative relationship between intrinsic religiosity and personal death anxiety in later life. One hundred forty-three older adult British Christians responded to both initial and follow-up postal surveys containing questions on their religious and death attitudes. Structural equation modeling analysis showed that intrinsic religiosity predicted lower personal death anxiety via fostering more benign afterlife beliefs and ego integrity. This study demonstrated that intrinsic religiosity had a negative indirect effect on personal death anxiety through the joint agency of more benign afterlife beliefs and greater ego integrity. It also provided empirical evidence in support of the role of intrinsic religiosity in promoting psychosocial well-being in later life.
Preparation for one's death (e.g., having signed a will, having made preparations for one's funeral) and preparation for future care needs (e.g., having selected a source of support) were investigated in 593 United States and 582 German independently living seniors. The older adults reported higher levels of preparation for death than preparation for care. The lower level of preparation for care is interpreted as reflecting the uncertainty whether care needs will emerge in the future. Seniors who reported some preparation for death were more likely to report preparation for future care needs as well. Older, more educated, and more religious individuals were more likely to prepare for death. In addition, U.S. seniors were more likely to report some death preparation than German seniors. Limitations in activities of daily living did not predict levels of preparation for death. Implications for future research and for psychosocial interventions are discussed.
In this article, the author, an eminent psychiatrist, psychotherapist, and writer, presents a brief introduction to the problem of human mortality as one of the givens of human existence, locating the problem squarely in the domain of self- awareness or human consciousness. He names the problem as death anxiety, a fear that can erupt into terror depriving an individual of happiness and fulfillment. Having identified the problem of death anxiety, the author then goes on, through a personal memoir, to disclose his personal ideas about death, their autobiographical sources, and how they have affected his life, as well as his coming to terms with the necessity of his own death. Within this autobiographical essay, he touches on experiences of death and dying from his youth, adolescence, and adulthood as well as his experience of the death of three of his most prized mentors: Jerome Frank, John Whitehorn, and Rollo May.