Be Not Proud— Meetfng the Needs of the Dyfng through Thassatology

Number12 March 23,1981

Death and dying are not particularly words still apply to man’s condition no pleasant or popular subjects. Oh yes, matter how firmly we do, or do not, be- people apparently want to hear about lieve in the hereafter or the finality of them in the news. They are indeed fasci- death. nated by this subject when it is por- As if dealing with our own eventual trayed in fihns, disaster reports, and the nonexistence were not enough of a like. But in the final analysis, death is a burden to carry afl our lives, some of us subject most of us prefer to avoid. must also deal with the unexpected There are enough reminders of it every of those we love. Children repre- day—in reports of wars, pestilence, and sent for many a form of , accidents and in the deaths of friends and so the loss of a child is a particularly and relatives, especially as one grows heavy blow. We pour so much love into older. our children and fear for them at every In recent years, J’ve experienced the turn, especially when they are infants. loss of several friends. Nobelist Harold And then suddenly death may come. Urey lived to the age of 87 and left the The effect varies from person to person world greatly enriched. 1 I recently at- and is often hard to describe adequate- tended a beautiful memorial meeting for ly. Last year I lost my daughter, Thea, Harold at Scripps Institution of Ocean- and it is a formidable step for me to ography in La Jolla, California. An old even say that here. But her life and friend and colleague, Fred Tate of death take on some added meaning if in Chemical Abstracts (CA ), died sudden- some way they make life’s problems ly.’2 We met when he worked at Wyeth easier for others to endure. And that is, Labs in Philadelphia. I often wonder in part, why I think the subject matter what would have transpired had he ac- of thk essay is so important. cepted my offer to come to ISP. But he Unexpectedly, when you go through helped change CA into a leading center a death experience you are surprised to for information retrieval. learn how many of your friends and Then I heard that my cousin, Harry associates have been there before. But Bauer, in far away Cape Town, South in spite of th~ experience, I myself have Africa, died. All such events are re- no prescription for coping with death. minders that life is finite. Ahnost 400 Though the death of someone we care years ago, John Donne wrote: “Death about is painful, most of us ultimately be not proud, though some have called find the strength to go on because life is thee/Mighty and dreadful, for thou art a wondrous and beautiful experience. not so ... . One short sleep past, we wake It is somewhat ironic that back m eternally/And death shall be no more; 1967 when I fiit wrote about ASCA” Death, thou shalt die.”s (p. 192) These (Automatic Subject Citation Alert),4 I

57 used death and dying as an example of a and children. People are living longer, topic on which it was difficult to retrieve and succumbing more often to such information. As I explain later, citation degenerative illnesses as cancer and searching was about the only way you heart disease. Biomedical advances could gather information on the sub- have made it possible for people to live ject. That has changed dramatically much longer with these illnesses that since the emergence of the field of earlier might have caused a rapid death. thanatology. The process of dying is now a clearly In the early 1970s, while speaking at a identifiable phase of life. This can be a Foundation of Thanatology conference painful period for the sick person and in New York, 5 I also noted that except his or her family. On a more positive for occasional articles appearing in scat- note, however, this period can provide tered journals, there was no periodical a the individual with an opportunity to thanatologist could turn to for specific put legal, financial, and emotional af- information on death and dying. Then, fairs in order and to say goodbye to as now, thanatology was a multidisci- family and friends. plinary field focusing on the psychologi- In previous generations, people died cal, social, and medical needs of the dy- in their homes, surrounded by people ing patient. In response to a 1977 and objects that held meaning for them. Special Libran”es6 article lamenting the Now, most people die in hospitals and lack of interdisciplinary coverage of nursing homes, away from their familiar death and dying, and , by environment. This change has deprived secondary information sernces, Tony the dying individual of many comforts, Cawkell, ISI’S former vice president of and has turned death into an isolated, research, did a Permuterm’z subject “unnatural” event that most people search on the word ‘{death.’’THe found rarely encounter. So when we must face the multidisciplinary nature of this sub- our own death or the death of someone ject was well-represented in the articles very close, we have no background of retrieved through the Social Sciences experience or knowledge on which to Citation Index” (SSCI ‘“). rely. The emotional coping mechanisms The 1970s was a period of growth for our grandparents developed as a result this discipline. As it expanded, the te~ of their more frequent and natural en- thanatology—taken from , the counters with death are not available to Greek god of death—took on added us. meaning. Thanatology now includes Even people who have frequent con- such topics as bereavement, anticipa- tact with death may find it difficult to tory , the social and psychological deal with their own death or that of effects of death on families, and the an- others. Physicians, nurses, and other ticipatory phases of life-threatening ill- health care providers—uncomfortable nesses such as heart and cardiovascular in the presence of death—may often disease. This growing field, following avoid dying patients or otherwise let the traditional patterns of pubfishksg,s.g them know they have given up. Thk has spawned several publications deal- kind of attitude is partially a reflection ing exclusively with death and dying. of the health care provider’s own anx- People have always died, or gone ieties about death, and his or her through the “process of dying. ” So why defense mechanism for coping with fre- this recent interest in thanatology? quent death and impersonal hospital There are a number of reasons, not the procedures. least of which is the success of medical This avoidance of dying patients can science in eliminating many of the dis- also be attributed to the medical com- eases that caused death among infants munity’s perception of itself as a ‘“cur-

58 ing” rather than “caring” force. Writing Research on the actual process of dy- of his personal encounter with cancer, ing began a bit later, in the 1950s. In Ralph Redding, Jackson Memorial Hos- work that has had a profound impact on pital, Miami, Florida, explains: “In future psychiatric treatments of death, medical training, death has become the Kurt R. Eisslerls wrote about the enemy; and in losing a patient, doctors psychiatric problems of the dying pa- often feel that they have failed medical- tient. A number of thanatologists trace ly, or worse still, made some terrible the origins of the current study of the mistake.”lo emotional aspects of dying to a 1956 Redding adds that medical schools American Psychological Association emphasize “fact oriented knowledge” meeting session on the topic of death. needed for diagnosing and treating pa- This session was organized by Herman tients. Doctors are not usuafly educated Feifel, VA Outpatient Clinic, Los to meet the emotional needs of their pa- Angeles, California, who edited one of tients. They are unable to discuss a pa- the earliest and most important scholar- tient’s impending death and, often, ly books in the field. lb It was the basis of under the guise of protecting the pa- the death and dying profile I created tient, don’t let that patient know he or when I first described ASCA to social she is terminally ill. scientists.4 This estrangement from death has led Much thanatology research is still di- a number of researchers to investigate rected toward determining and meeting the emotional processes of the dying the needs of a dying person, and helping person and the people who share thk that person’s family through what psy- phase of his or her life. It has also insti- chiatrist Elisabeth Kiibler-Ross calls this gated research into bereavement and “final stage of growth’ and bereave- grief. In an excellent review of the ment. 17A number of very strong princi- historical development of death educa- ples about patient’s rights emerge from tion, Vanderlyn R. Pine, State Universi- a review of the death and dying ty of New York at New Paltz, points out literature. These are cogently summa- that interest in bereavement preceded rized by Daniel R. Longo, National interest in the dying process. 11Another Naval Hospital, Bethesda, Maryland, good review of is and Kurt Darr, George Washington presented by Dan Leviton, University of University. They write: Maryland, in New Meanings of Death. 12 The terminally ill: (t) must be given Although studies and case reports on the possibility of achieving accep- bereavement and practices were tance of death with dignity; (2) have published sporadically in the 1920s and rights, including the right to be in- 1930s, Pine credits psychiatrist Erich volved in decision-making processes; Lkdemann, Harvard University, with (3) should be allowed to die as they have lived-family and friends espe- providing the foundations for many of cially have the role as caretakers; (4) today’s theories on bereavement, grief, should be made as free from as and . In the 1940s Lindemann possible; and (5) should be regarded found that more than 80 percent of pa- as persons who are going through a tients suffering from ulcerative colitis natural, rather than an unnatural pro- had a poorly managed grief experience cess. la in the six months preceding the onset of One of the initial findings of studies symptoms. 13He and hk colleagues also on dying patients was that many, with- noticed that patients in acute grief as a out being told directly, are aware of result of a major fire healed measurably their impending death and wish to slower than those who had experienced discuss it. In a seminal study of patients no grief. 14 iying in a London hospital, J.M. Hinton,

59 Mlddlesex Hospital, reported “.. .at unique phase of life, and that dying peo- least three-quarters of the patients... ple have needs that are not being fully became aware they were probably dy- met in current social institutions. Of ing . ...” He concluded, “The problem particular concern is the terminally ill (of determining whether a patient patient’s need for relief from the pain should be told he or she is dying) .. . that often accompanies the final stages resolves itself into discovering what the of iflnesses such as cancer, and heart patient knows, and how much more he and neurological disease. Many health really wants to know, information that care providers have found that the im- can be gathered with no distress in a personal atmosphere of most hospitals, quiet, unhurried conversation. In my and feelings of isolation and loneliness opinion, if the awareness of the patient from being in unfamiliar surroundings, is so great that he has formulated the can exacerbate this pain. Unfortunate- question, an honest answer which does ly, the need for medication and other not destroy all hope will not add to his medical intervention, and pressures on distress.” 19 the family, can make it difficult for a In an effort to understand the experi- terminally ill person to die at home. ences of a dying person, and help him In England and, more recently, the through this final phase of life, a US, the concept has been re- number of investigators have described vived to meet the dying patient’s need “stages” or “phases” dying patients go for a peaceful environment where both through after learning of their terminal medical and emotional support can be illness. These stage theories have been provided, Robert Butler, director of the reported in the academic Literature, zo National Institute on Aging in the US, and were brought to the public by describes the hospice as “a place Kubler-Ross in her 1969 book, On dedicated to providing comfort, support Death and Dying.21 Briefly, the five and dignity for those who are dying. ”zz stages identified by Ktibler-Ross are: (1) are the modern versions of denial and isolation (“No, not me, it hostelries for pilgrims operated in the cannot be true,”); (2) anger (“Why Middle Ages by religious centers seeking me?”); (3) bargaining (entering into to fulfill the Biblical directive: “Inas- some sort of an agreement which may much as ye have done it unto one of the postpone the inevitable happening); (4) least of these My brethren, ye have depression; and (5) acceptance. Of done it unto Me.”zJ Like their earlier course, dying is a highly individualized counterparts, many hospice workers are process and dying people do not rigidly dedicated to serving God by caring for follow this or any other model, the sick and dying on their “last Tillman Rodabough, Baylor Universi- journey.” ty, in a recent review of three such Although a few of the almost 200 models, suggests that individuals vacil- hospices listed in the National Hospice late between acceptance and denial Organization’s Member Locator Direc- even when they do follow a given be- tory24 are free standing, residential havioral model. Describing his “Inter- buildings, a different hospice concept is personal Reactions Model,” Rodabough emerging in the US. As described by proposes that a dying person-taking Butler, hospice “..must be viewed as a cues from the people around him or body of knowledge, an array of prac- her—behaves and expresses the emo- tices, and a set of concepts and attitudes tions expected by the observer.zo that emphasize comfort, support and Thanatological investigations have dignity for the dying and their led to an awareness that dying is a surnvors. ”zs This concept has caught

60 on in the US and hospices in thk coun- (heroin) and cocaine is currently being try range from the large unit in Branford administered to dying patients in the (New Haven), Connecticut, which UK. What Butler describes as “exceUent serves only terminal patients to the pain control”zs has been achieved with “scattered” type of hospice at St. this mixture. As a result, the National Luke’s Hospital in New York, where ter- Cancer Institute in the US has devel- minally ill people are interspersed with oped stable dosage forms of heroin other patients, but attended by a special which have been used in research proto- staff. Many hospices are actuafly home cofs at Memorial Sloan-Kettering Can- care programs in which a staff serves dy- cer Center and Georgetown University. ing patients, as needed, in their homes. This mixture, known as Brompton’s Since hospices are dedicated to car- cocktail or mix, the pain cocktail, or the ing for the dying, rather than curing hospice mix, is more commonly admin- disease, hospice workers’ attitudes istered with morphine or methadone,2T toward pain management differ from rather than heroin, in the US. A good those of individuals caring for people review of clinical use of this mixture is who are likely to recover from illness, presented in a 1974 article by R.G. and therefore, must not be allowed to Twycroas, St. Christopher’s Hospice.~ become addicted to painkillers. Butler Saunders stresses that, properly ad- and the majority of people involved in ministered, these drugs need not lead to the “hospice movement” believe pre- drug dependence or tolerance.zb scription practices should allow ter- One of the contributions of those minal patients to feel as little pain as concerned with the terminally ill has possible. This usually means administer- been the attention they have focused on ing pain relief before any pain is felt. better means of chemical, surgical, and Butler writes: psychological pain control. The Na-

In this way, it is possible to erase tional Institute on Aging (NIA) is sup both the memory and fear of pain, porting research on the pharmacology thus enabting the patient to review his of aging and is a participant in the joint or her life in peace and come to terms NIA-Alcohol, Drug Abuse and Mental with approaching death. This ap- Health Administration, Interagency proach differs from the currently Committee on New Therapies for Pain fashionable.. .’as necessary’ regimen, and Discomfort .25 whereby the patient is allowed to develop pain, must then wait while it The ND-4 is also funding research on worsens (complaining is discouraged), the reaction of the patient’s survivors and finally calls for a nurse, who ad- both before and after his death. Re- ministers the drug at her or his earliest searchers are looking at the stages the convenience. More time is needed for family goes through in accepting the the medication to take effect, and the death of a member, the roles played by dying person’s last hours are filled with anxiety, anger and cyclical religion and ritual in helping people pain. 22 come to terms with death, the incidence ~f morbidity and mortality among griev- Both Butler25 and Cicely Saunders,2c ing people, and other physical, social, medical director of St. Christopher’s and psychological effects of bereave- Hospice, England, stress that pain ment. relief, rather than addiction, should be Much of the bereavement research the concern of doctors administering to done in the past 30 years has built on the the terminally ill. The British gover- Findings of Lindemann and his col- nment, apparently, agrees. An oral medi- leagues, whom I mentioned earlier. cation which inchtdes diamorphine I’heir reports on the adverse physicaf ef-

61 fects of bereavement have been con- Roy and Jane Nichols, funeral direc- firmed by a number of investigators. For tors, advise their colleagues not to example, A. Schmale, Rochester Uni- sh~eld mourners from pain and to permit versity, found that 98 percent of the pa- them as much involvement in the funer- tients admitted to Strong Memorial al process as possible. They -write: “We Hospital in Rochester, New York, dur- cannot take the pain away. Whereas the ing a 23-day period experienced loss (of grieved person may want withdrawal an object or person), accompanied by from reality (who wouldn’t), there is fre- feelings of helplessness and hopeless- quently a strong difference between ness, prior to the onset of illness. zg what people want and what they need. Similarly, a study reported in England in We all must be aware of the extreme 196N and followed up in 196931 found dangers of delayed, avoided grief and that widowers’ was ‘“40?70 must develop the skills, the openness, above the expected rate for married the accepting attitude which will allow men the same age.” More recently, in a the grieved person to accept the death review of epidemiological studies con- he has sustained. “36 According to ducted since 1959, Adrian Ostfeld and Leviton, funeral directors, because of Selby Jacobs, Yale University, con- their experience with the bereaved, cluded there may be an excess mortality have come to play an important role in of several thousand Americans annually the resolution of grief.J? But thk can as a result of significant personal ~oss.gz largely depend upon how well the family Bereaved individuals are evidently an is known to the . “’at risk” population. It is therefore not Platitudes and clicht% are not particu- surprising that psychologists and psychi- larly welcome at such crises. atrists, among others, have investigated The next stage of grief is what Pincus the grieving process and the conse- calls the “controlled phase.” Thk can be quences of being unable to healthfully the most painful period for the moum- “’work through’ this grief. er. The shock and numbness of the ear- A number of different “stage” models lier phase have worn off. The little of the grieving process have been ad- things that make up a relationship make vanced by researchers and thera- themselves known at this point, and the pists.q~Js All generally follow the bereaved feels lost and abandoned. Peo- course described by Lily Pincus, ple often, consciously and unconscious- Tavistock Institute of Human Relations, ly, search for the lost person by looking London, in her book Death and the for his or her face in a crowd, or by hav- Family .35 According to Pincus, most ing dreams and hallucinations about the people initially react with shock, deceased. People can be restless and disbelief, and denial. Often family and tense during thk time and need the sup- friends try to help by sedating the port and safety of family and friends. mourner and advising him or her to During this stage, the physical and keep busy, thus avoiding facing the psychological manifestations of grief death. Such advice, psychologists, can be very real and acute. Dennis M. ministers, and family therapists agree, is Reilly, SNG Counseling Center, Wan- wrong because it sets the stage for fur- tagh, New York, cites such symp- ther denial of loss and pain. If delayed, toms as panic attacks and hysteria, the pain, anger, and guilt repressed at nausea, dizziness and digestive upsets, this point will surface later in some insomnia, impotence, and identification unexpected and unhealthy fashion. The with the deceased and his symptoms. ~ longer grief is denied, the more virulent The final stage is adaptation, or reso- its expression. lution of the grief. At this point, the

62 mourner can withdraw the emotional at- the UK, Canada, and Australia. Leviton tachment to the loved person and can attributes the large number of articles think, talk, and feel about him or her written by people in the US to our per- without the intense pain of the earlier vasive need to control our lives. He stage. Pincus describes this as “internal- points out that the US also leads the izing” the deceased. Edgar N. Jackson, world in research and education on sex, a consultant and author, compares the another generally taboo subject. sT emotion of grief with physical amputa- A number of clinical, as well as tion and its resolution with adjustment academic and thanatological, journals to missing a limb, He describes grief as now publish articles on death and dying. “removal of part of the feeling structure Usually these articles describe counsel- of life... ” and offers th~ explanation of ing and other special programs for dying the bereavement process: “The root patients, and educational or counseling emotion of grief grows from this identi- programs to help physicians, emergency fication with another so completely that room personnel, nurses, and other health a part of our own being lives and feels care providers cope with the death of pa- with that person . ... Mourning is the tients. Although these people have fre- process by which the emotional capital quent exposure to death, they have not invested in the love object is withdrawn until recently been taught how to help a so that it can be reinvested where it can dying patient come to terms with his or do good in life .“B~ Emotional bondage her death. The importance, and popuktr- to the deceased must be broken before ity, of courses on death and dying is grief can be resolved. reflected by the fact that a journal was Although there are no hard and fast started three years ago to deal with the rules, the period of intense grief is spectilc subject of death education. It is, generally passed by the ftith or sixth very appropriately, entitled Death month while the end point of grieving Education. Published in association with seems to arrive between one and two the Center for Gerontological Study and years after the death. A person who Programs at the University of Florida, grieves weff beyond this period clearly this journal carries articles covering the needs professional psychiatric or psy- $pectmm of thanatological d~ciphnes. chological help. Doctors Jacobs and For more information on this journal, Ostfeld advise physicians to be familiar contact the Hemisphere Publishing with the grieving process so that they Corp. , 1025 Vermont Avenue, NW, can listen to and validate their patients’ Washington, DC 20005. emotional responses to loss. When a Another journal, OMEGA: Journal bereaved individual is not being given >fDeath and Dying, carries research the opportunity to grieve, they recom- -eports on various aspects of thanatol- mend the physician meet with the family >gy. Started in 1966 as a newsletter for to validate the survivor’s experience. If nterested scholars, this journal has a patient cannot resolve his or her grief, >ecome the official publication of the if he or she feels out of control, or ?orum for Death Education and delays or prolongs the grieving process, ~ounseling. The Forum is an organiza- they suggest the mourner receive thera- tion of researchers and educators con- peutic help.~ :erned with promoting and upgrading In reviewing the thanatology litera- he quality of death education and dying ture, one cannot help but notice that md bereavement counseling. They of- the majority of articles were written by ‘er workshops on death education and scholars and educators from the US. A :ounseling in several cities in the US great deal of work is also being done in md can be contacted by writing Forum

63 for Death Education and Counseling, toberta Halporn at Highly Specialized Inc., P.O. Box 1226, Arlington, Virginia ‘romotions, 391 Atlantic Avenue, 22210. OMEGA is published by the lrooklyn, New York 11217. Baywood Publishing Company, Inc., Thanatology is a firmly entrenched, 120 Marine Street, P.O. Box D, Farm- multidisciplinary field. Beyond its direct ingdale, New York 11735. contributions to the needs of dying and Advance$ in T’hanatology (formerly )ereaved individuals, it promises to The Journaf of Thanatology) is the offi- mrich the knowledge of a number of cial publication of the Foundation of Mferent disciplines. Psychologists and Thanatology. Thk educational and iochl workers are helping physicians scientific organization has sponsored md nurses understand the role played more than 30 symposia on issues related )y the patient’s environment, and men- to death and dying. These symposia :al and emotional states, in pain control. have generated a number of research philosophers and clergy are helping reports, monographs, and over 40 ~sychologists, social workers, and books. The Foundation also publishes ineral directors understand and use the Archives of the Foundation of ituals that aid in acceptance of death Thana/o/ogy, a quarterly journal of md the resolution of grief. Although abstracts and some full papers from [here now are many expressly thanato- symposia, and Thanatology Abstracts, ,ogical joumals, literature of interest to which summarizes published articles. thanatologists can be found in a wide For information on all three publica- vanet y of joumals. Even the organiza- tions write the Foundation at P.O. Box tions that fund thanatological re- 1191, Brooklyn, New York 11202. The search—the National Institutes on Ag- Foundation is closely associated with ing and Mental Health and the National the College of Physicians and Surgeons Cancer Institute-represent a variety of at Columbia University and can be disciplines. reached through Austin H. Kutscher, Unfortunately, every advance in tech- President, 630 West 168th Street, New nology has increased the chances for ac- York, New York 10032. cidental death—whether in an airplane, Essence, a Canadian thanatological or a car, or by some other means. Since journal, can be obtained by writing the the probability of nonnatural death is editor, Stephen Fleming, at York Uni- increased, as with every other type of versity, Atkinson College, 4700 Kee[e medical emergency, we need to know Street, Downsview, Ontario M3J 2R7, how to cope with it. For this reason, the Canada. The official publication of the field of thanatology is clearly a disci- American Association of , pline that will grow until our education and Life-Threatening Behavior, and make knowledge of the pro- Human Sciences Press, 72 Fifth cesses of death, dying, and bereavement Avenue, New York, New York 10011, commonplace. Even when death is no also carries articles of interest to thana- longer an implicitly taboo topic, there tologists. OMEGA, Essence, Suicide will still be a need for professional and Life- Threatening Behavior, and knowledge of how to deal with dying Death Education are covered by Cur- and bereavement. Death education and rent Contentsm/Social & Behavioral research will continue to help thousands Sciences and the SSC1, of people cope with these painful phases Individuals interested in obtaining of life. specialized bibliographies on thanato ***** logical subjects or the Thanato/og~ My thanks to Joan Lipinsky Cochran Librarian, a newsletter which review! and Patn”cia Hel[er for their help in the books on death and dying, can wntt preparation of this essay, 0!98,5,

64 REFERENCES

1, G*ME. Atribute to Harold Umy. Cuvenf Consents (49): S-9, 3WcemMr 1979. 2. Tateof Caddies, Chem. Eng. News 58(47):8, 24 November 1980. 3. Donna J. Holy Sonnets X: Death Be Not Proud. (Harrison G B, cd. ) Major Bn’ti$h writers, New York: Harcourt, Brace & World, 1%7. p. 192. 4. Gufkfd E & Sher I H. ASCA (Automatic Subject Citation Alerf): a new persrmafized current awareness service for scientists. Amer. Beha v, Sci. 10:29-32, 1%7. 5. GarffeJd E. Information problems in thanatology. (Fleming T J, Kutscher A H, Peretz D & Goldberg I K, e&.) Communicating issues in thamrtology. New York: MSS Information Corporation, 1976. p. 221-9. 6. Gardner T & GnmJyaar M L. The inadequacy of interdisciplinary subject retrieval. Special Lib. 6&193-7, 1977. 7. Cawkeff A E. Letter to editor. Special Lib. (Unpublished), 26 May 19T7. 8. Garffefd E. The epidemiology of knowledge and the spread of scientific irrformation. Current Conlenu (35):5-10, 1 September 19S0. 9. ------What a difference an “A” makes. Current Corrferrm(27):5-12, 2 July 1979. 10. Reddfng R. Doctors, dyacornmunication, and death. Death Educ. 3:371-85, 1980. 11. Phre V R. A socic-hiatoricaf rmrtraitof death education. Deaih Educ. 1:57-84, 1977. 12 Lavltorr D. Death education. ‘(Feifel H, ed. ) New meanings of death. New York: McGraw-Hill, 1977. p. 253-72. 13 LbrdemmmE. Psychiatric problems in conservative treatment of ulcerative colitis. Arch. Neurol. Psychiat. 53:322-4, 1945. 14 Cobb S & LfndemamrE. Neuropsychiatric observations. Ann. Surg. 117:814-24, 1943. 15. Efaaler K R. The psychiatrist and the dying patient. New York: Intema!ional Universities Press, 1955. 400 p. 16. Feffel H, ed. The meaning of death. New York: McGraw-Hill, 1959.351 p. 17. Kiibler-Rnas E, erk. Death: the find $tage of gro wth. Englewood Cfiffs, NJ: Prentice-Hafl, 1975.181 p, 18. Lorrgo D R & Darr K. Hospital care for the terrninafly ill: a model program, HOSP. Prog. 59:62-5, 84, 1978. 19. Hfnton 1 M. The physical and mental distress of the dyirrg. Quart. J. Med. 32:1-21, 1963. 20. Rodabough T. Alternatives to the stages model of the dying prwsess. Death Educ. 4: 1-!9, 1980. 21. Kiibler-Russ E. On dea[h and dying. New York: Macrniffan. 1%9. 289 p. 22. ButJar R N. A humanistic approach to our last days, Death Educ, 3:359-61, 19S0. 23. Matthew 25:40. 24. National JJoapke OrgurJzatJorr. Member locator directory. McLean, VA: National Hospice Organization, 1980. 98p. 25. ButJer R N. The need for quality hospice care. Death Educ. 3:215-25, 1979. 26. .%undem C. Termimd care. (Bagshawe K D, cd. ) Medics/ oncology. Oxford: Blackwell, 1973. p. 563-76. 27. Mc(%ffray M, Mona M E, Grnm J & Morfrz D A. Dea/ing with pain, New Haven, CT: American Cancer Society. 80 p, 28. Twycroas R G. Clinical experience with diamorpbine in advanced malignant disease. hrt.J.Clirr. Pharrrracol. 9:184-98, 1974. 29. Schrnafe A H. Relationship of separation and depression in disease. I. Psychosom. Med. 20:259-77, 1958. 30. Youmg M, Benjamfn B & W?dffs C. The mortality of widowers. Luncet 2:454-7, 1%3, 31. Parkes C M, Benjamfn B & Fftagernld R G. Broken heart: a statistical study of increased mortafity among widowers. Bn’t. Med. J. 1:740-3, 1%9. 32. Jacobs S & Ostfeld A. An epidemiological review of the mortality of bereavement. Psych osom. Med. 39:344-57, 1977. 33. Lfndemarrn E. Syrnptomatology and management of acute grief. Amer. J. Psychia( 101:141-8, 1944. 34. Pukes C M. Berea vemerrc studies of gn”ef in adu/t life. New York: International Universities Pres 1972.233 p. 35. Pfrrcus L. Death and [he family. New York: Pantheon, 1974.278 p. 36. Nkbols R & Nkbok J. : a time for grief and growth. (Kiibler-Ross E, cd. ) Dearh: dre final $tage of growth. Englewood Clifs, NJ: Prentice-Hall, 1975. p. 87-%. 37. Levfton D. Telephone communication, 18 December 1980. 38. RefUy D M. Death propensity, dying and bereavement. A farniky systems perspective. Fare. The.. 5:34-55, 1978. 39. Jackson E N. Wisely managing our grief: a pastoral viewpoint. Des/h Educ. 3:143-55, 1979. 40. Jacobs S & Ostfeld A. The clinicsf management of grief. J. Amer. Genut. SOc. 28:331-5, 1980.

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