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COPYRIGHT 2001 JAI Press, Inc.
Let us deal with the human condition as we find it: in ever changing, ever renewing drama (Sabrin, 1977, p. 39)
1. Introduction
"Old Goriot," a classic portrait of Parisian society, portrays Goriot dying, while holding on in hopes that his two daughters would appear to comfort his last hours. They did not appear before Goriot died (Balzac, 1951). A comparison could be created between the book and actual life concerning the wishful and actual final scenes of life. Balzac's (1951) book portrays in fiction the ways in which individuals build an image of their "good death," their ideal script for the final act. These images often go beyond the deathbed scene as the dying person envisions the completion of an entire life and its legacies (Kastenbaum, 1994; Leichtentritt & Rettig, 2000).
This study is the second phase of a research project aimed at reaching an inductive understanding of "the good death." The current phase of the study emphasizes the strategies elderly individuals use while describing the good death. The emphasis on strategies of description is important since reaching a comprehensive understanding of a phenomenon requires paying attention not only to what appears, but also to the ways in which things appear, including the strategies individuals use while constructing their viewpoint of the good death (Spiegelberg, 1960). The process of constructing an experience or event is referred to in the literature as "meaning-making" activity. The goal of the current research is to recognize the meaning-making strategies individuals use while constructing the good death experience.
Meaning making is "a social act whereby an actor interprets stimuli in a setting and represents the situation to him or herself in symbolic terms" (Nadeau, 1998, p. 15). Individuals engage in meaning-making activities in order to resolve issues and understand life events and their implications (Davis, Nolen-Hoeksema, & Larson, 1998; Frankl, 1984; Janoff-Bulman, 1992), since meaning "exists only when implicit knowledge is conveyed explicitly to another" (Hinds, Chaves, & Cypess, 1992, p. 62). Individuals further engage in meaning-making activities in order to clarify purposes and values (Samarel, 1995), and arrange activities surrounding threatening life events, such as death and dying, so that a coherent and reasonable account is constructed (Moos & Schaefer, 1986; Parkes & Weiss, 1983).
The good death has been recognized as a multidimensional phenomenon based on physiological, personal, interpersonal, social, and cultural domains of life that incorporate past, present, and future time periods (Leichtentritt & Rettig, 2000). The multidimensional perspective describes the good death as a process that is influenced by both individual wishes and social norms and laws (Emanuel & Emanuel, 1998; Leichtentritt & Rettig, 2000). The theoretical and scholarly justifications for the current study lie in the lack of knowledge concerning the good death phenomenon (Byock, 1997; Kastenbaum, 1994). Emanuel and Emanuel (1998) described a paradoxical situation in which scholars are increasingly concerned about death and dying, there are tremendous technical capacities available to relieve symptoms and improve care, but yet we persistently observe the suffering of dying patients and continue to deny death. In order to resolve this paradoxical situation, scholars (Emanuel & Emanuel, 1998; Mayo, 1998) have recently urged researchers to put biases aside and closely examine what terminally ill and elderly people have to say about the "good death." How do elderly people perceive the good death? How is the best scenario constructed? What does this scenario contain? What are some of the modifications that need to be made in order to provide the options for elderly people to experience a good death?
The research goal of identifying the meaning-making strategies individuals use while imagining the good death cannot be achieved if ignoring the social contexts in which the phenomenon is constructed. Mishler (1979) emphasized that all human experience is context-dependent and can only be understood within those contexts. Social histories, rituals, norms, and laws assist individuals in constructing the good death by specifying the: appropriate place in which death should occur, procedures involved in the dying process, roles of the dying person and his/her family members, as well as the professionals who are involved in the process. Social norms further specify the structure and forms of rituals following the death of a close family member.
The environmental context of the current study is the Israeli society where death is very much a part of the daily societal fabric due to the many wars and terrorist activities the country has faced and the constant legacy of the Holocaust (Silverman, Weiner, & El-Ad, 1995). Nevertheless, death within this context is an unexpected, sudden tragedy. Natural dying experiences are a neglected area of study (Malikinson, Rubin, & Witzman, 1993; Shamgar-Handleman, 1986) and an unlikely topic of discussion within Israeli families (Gilbar & Steiner, 1996; Leichtentritt & Rettig, 1999).
The prescribed norms and rituals regarding death and dying in Israel are strongly influenced by the Orthodox Jewish traditions (Abramovich, 1991; Sobel & Beit-Hallachmi, 1991). The Jewish tradition emphasizes the precedence of human life over all biblical injunctions (Rosner, 1991). Therefore, the individual's fights for end-of-life decisions have only recently emerged in Israel (May 1996) and include the right for withholding and withdrawing treatment (passive euthanasia). These rights, however, are currently being implemented with many difficulties (Glick, 1997; Resnik, 1998) because hospitals tend to use technology to the fullest extent following the social and religious norms of fighting death at nearly all costs (Glick, 1997; Shuval, 1992). The dying and mourning processes are further influenced by the Orthodox Jewish perspective and follow strict interpretations of the Jewish law. The funeral in Israel takes place within 12 to 24 hours after the death, is arranged by the burial society, and is paid for by the state (Abramovich, 1991). There is no public viewing of the body and the body is not buried in a coffin.
These strong norms highlight the need to examine the ways in which elderly Israelis construct the good death in a culture that prescribes one way to die, one way to be buried, one way to mourn over the loss of a close family member; and further tends to block open communication about natural death and dying. The results of this research will contribute to our universal knowledge about death and dying while highlighting the unique characteristics of the issue within the Israeli society. The current study follows DeSpelder and Strickland's (1994) observation that understanding how people in various cultures approach death assists us in shedding light on our own perspectives.
2. Method
2.1. Informants
Twenty-six older adults participated in this study which identified meaning-making strategies that were used while constructing the good death phenomenon. To participate in the study, the adult had to be at least 60 years of age, independent in everyday activities, and reside in the community. These criteria were selected in order to involve people who were less constrained by current life situations in their thinking of the good death. Participants were located by the use of advertisements, personal connections, and the chain sampling technique (Patton, 1990). The initial contact with them was by telephone to explain the study and all but one of these persons expressed an interest and agreed to prticipate. Fifteen of the participants were women, six of whom were widows. Among the 11 men, one was a widower and one was never married. Four participants labeled themselves as religious Jews and the others as secular.
Israel is a small country with a diverse population due to the fact that it is an immigrant society. It is important to mention that Jewish rituals and customs of dying and bereavement have been modified by the immigrants' countries of origin (Silverman et al., 1995). Only two of the participants in the current study were born in Israel. Most of them arrived in their late adolescent years from areas that included Central and Eastern Europe, South America, North Africa, and the Middle East.
2.2. Personal interviews
Individual interviews were conducted with the informants during the summer of 1997. The median interview duration was approximately 2 hours, with a range from 1 to 4 hours. All interviews took place at the participants' homes and were conducted in Hebrew. The interviews covered: (a) family characteristics, personal health status, and religiosity; (b) the participants' experiences with death and dying; (c) descriptions of the ideal death; (d) concerns about death, dying; and (e) attitudes and behaviors related to the anticipated losses. Examples of questions included: If you could choose, then how would you like death to occur? Can you describe the process? Do you know anyone whose death was a good one? Can you describe this experience? Follow-up interviews were completed with 4 of the 26 informants in order to clarify their perspectives.
2.3. Ethical considerations
Several ethical challenges were potentially problematic in the described research. First, the interviews brought forward painful memories and high levels of anxiety. Sharing personal thoughts about potential dependence, death, and dying elicited strong feelings of discomfort and ambiguity that people typically try to avoid (Vandecreek & Frankowski, 1996). Second, the fact that death and dying in the natural ways have rarely been discussed in the family or at the social/public level, resulted in informants who admitted they had never before spoken to anyone about these issues. Third, the research questions, by referring...
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