1. This is my play’s last scene: Death Rituals in America GEC Faculty Scholars July 26, 2013 Michael D. Barnett, MD, MS Assistant Professor of Medicine & Pediatrics UAB Center for Palliative & Supportive Care

2. Objectives 1.To describe the importance of ritual in death and dying. 2.To list common cultural customs surrounding death in America. 3.To recognize our role in the death rituals of our patients. 4.To reflect on ritual as part of our personal grieving process as clinicians.

3. Universality Death of elderly chimpanzee at a zoo in UK, 2010. Pre-death caregiving All-night vigil at time of death Testing for signs of life Male aggression towards corpse Cleaning of the body Mourning period Anderson, JR, et al. (2010) Current Bio. 20(8):R349-51.

4. Rituals Arnold van Gennep, French folklorist, published his model on rites of passage in 1960. Hunter, J. (2008) OMEGA. 56(2):153-73. SeparationTransitionReintegration

5. Death Rituals Rites of passage that serve specific purposes surrounding death: 1.Provide social support to mourners. 2.Set limits to formal mourning. 3.Outline cultural obligations during mourning. 4.Restore the bereaved to society. Hunter, J. (2008) OMEGA. 56(2):153-73.

6. Death Rituals Medicine Religion/ Spirituality Psychology Sociology

7. Dying in America In 2007, there were 2.4 million adult deaths in US  50-90% of adults prefer to die at home.  50-60% of adults die in the hospital. We are players in our patient’s last scene. Xu, J., et al. (2010) National Vital Statistics Report, 58(19). Bell, CL, et al. (2010) J Pain Symptom Manage. 39(3):591-604.

8. Anatomy of a Scene Preparing for death Preparing the body Preparing for burial Preparing for life apart African American Hindu Islamic Jewish Western (Christian)

9. African American “No one has power over the wind to restrain the wind, or power over the day of death.” - Ecclesiastes 8:8

10. background  Blending of African & Christian traditions  Death as “transition”  More familiarity with death  Mistrust of hospitals & physicians Personal reflections of rituals… Collins, WT & A. Doolittle (2006) Death Studies, 30:957-69. McIlwain, CD (2002) Qual. Res Reports in Comm., Winter 2002:1-6.

11. Preparing for Death  Importance of community: Physically gathering at the bedside Group decision-making  Medical decisions & funeral services often delayed Barrett, RK & KS Heller (2002) J Palliat Med. 5(5):793-800.

12. Preparing for Burial  The wake or “sit up” Body brought back home if possible ”Home-going” celebration Display of respect (i.e. giving them the best)  Emotional displays may be expected or encouraged Barrett, RK & KS Heller (2002) J Palliat Med, 5(5):793-800. McIlwain, CD (2002) Qual. Res Reports in Comm., Winter 2002:1-6.

13. Preparing for burial New Orleans Jazz Funeral  Procession of band, casket, family & friends  Display of solidarity (“second-line”)  Dirge progressing to upbeat music  Passes by places important to deceased Bordere, TC (2008) OMEGA, 58(3):213-32.

14. Preparing for burial

15. Preparing for Life Apart T-shirts & tattoos as symbols of remembrance  Photo, name, birthday, date of death  “Gone but not forgotten” Bordere, TC (2008) OMEGA, 58(3):213-32.

16. Hindu “Because death is certain for the one who is born, and birth is certain for the one who dies. Therefore, you should not lament over the inevitable.” - Bhagavad-Gita 2:27

17. Background Karma—birth & death part of cycle of actions which lead to reincarnation or absorption into Brahman Multiple deities, each with devoted following:  Brahma (the Creator)  Vishnu (the Preserver)  Shiva (the Destroyer) Clements, PT, et al. (2003) J Psychosocial Nurs, 41(7):18-26.

18. Preparing for death  Fasting  Singing of hymns (bhajans)  Body laid on ground just before death with head facing south Firth, S. (2005) Lancet, 366:682-6.

19. Preparing for death “Good” death:  Old age  Right astrological time  Right place  Shining forehead  Peaceful expression  Eyes & mouth open “Bad” death:  Premature  Violent  Wrong time  Wrong place  Unpleasant expression  Vomit, urine or feces Firth, S. (2005) Lancet, 366:682-6.

20. Preparing the body  Body bathed, massaged with oils, dressed in new clothes Ganges water on lips Basil (tulasi) leaf in mouth Eyes & mouth left open  Sacred ash (bhasma) or sandalwood paste applied to forehead Firth, S. (2005) Lancet, 366:682-6.

21. Preparing for burial Antyesti—funeral rites  Oldest son (or priest) places flowers around body & lights funeral pyre  Ideally before next sunrise Lobar, SL, et al. (2006) Pediatr Nurs, 32(1):44-50.

22. Preparing for life apart Formal mourning—10 days of prayer & abstinence  Oil lamp kept lit at home  On 10 th day, lamp taken to water & released Shradh—month-long ceremony at 1 st anniversary  Prayers made for the deceased  Food given to poor  Restrictions on new clothes & parties Clements, PT, et al. (2003) J Psychosoc Nurs, 41(7):18-26.

23. Islamic “Wherever you are, death will overtake you, though you are in lofty towers.” -Qur’an 4:78

24. background Shari-ah (Muslim law) derived from Hadith (practice & sayings of Muhammad) Maut—signs of death: 1. Legs become limp 2. Breathing becomes heavy & erratic 3. Nose bends slightly 4. Temples sag Gatrad, AR (1994) BMJ, 309:521-3. Sarhill, N, et al. (2001) Am J Hospice Palliat Care, 18:251-5.

25. Preparing for death Death seen as a chance to recite or redeclare faith  Use of talismans or lockets  “Consumption” of verses Lundquist, A, et al. (2003) J Perinatal Neonatal Nurs, 17(1):77-86. Sarhill, N, et al. (2001) Am J Hospice Palliat Care, 18:251-5.

26. Preparing the body  Face turned to Mecca (or southeast or right) Mouth & eyes are closed Ritually bathed Wrapped in shroud (kafn)  Body kept intact No organ donation No mementos of deceased Gatrad, AR (1994) BMJ, 309(6953):521-3. Lundquist, A, et al. (2003) J Perinatal Neonatal Nurs, 17(1):77-86. Sarhill, N, et al. (2001) Am J Hospice Palliat Care, 18:251-5.

27. Preparing for burial  Burial within 24 hours preferably No embalming or cremation No open caskets No coffins or simple coffins only No flowers  No loud wailing or tearing of clothes Women may not be allowed at funerals or cemeteries Clements, PT, et al. (2003) J Psychosoc Nurs, 41(7):18-26. Gatrad, AR (1994) BMJ, 309(6953):521-3. Sarhill, N, et al. (2001) Am J Hospice Palliat Care, 18:251-5.

28. Preparing for life apart  Formal mourning may last for 3 to 40 days Iddah (period of waiting)—4 months + 10 days for widows Shoes removed when entering house of deceased Head covered when talking about deceased Gatrad, AR (1994) BMJ, 309(6953):521-3. Sarhill, N, et al. (2001) Am J Hospice Palliat Care, 18:251-5.

29. Jewish “He uncovereth deep things out of darkness, and bringeth out to light the shadow of death.” - Job 12:22

30. Background  Three main branches—vary based on adherence to Halakha (Jewish Law) Orthodox Conservative Reformed  Sacred privilege to be present at the time of death Clements, PT, et al. (2003) J Psychosoc Nurs, 41(7):18-26. Loike, J, et al. (2010) J Palliat Med. 13(10):1267-71.